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PubMed1996

Concurrent utilization review and inappropriate hospital stay: evaluation of a program.

Using a crossover design, we tested the hypothesis that concurrent utilization review by a utilization officer would reduce length of stay and inappropriate bed days in a tertiary care hospital. The intervention groups included 396 consecutive patients admitted to specified services during two 1-month study periods and followed for at least 1 month or until discharge. Controls were 410 patients admitted to the same services during a preceding or subsequent month, separated by a 1-month washout period. Intervention cases had daily review of their care plan and medical condition by the utilization officer to identify existing or likely inappropriate hospital stay. The officer used interdisciplinary and interdepartmental consultation in attempting to resolve identified problems. A separate research nurse identified the controls and gathered data on the medical condition and care plan for a random 50% sample of both intervention and control cases. These data were used by a multidisciplinary panel to count and classify the reasons for inappropriate hospital days. Overall, there were no significant differences between the corresponding intervention and control groups for length of stay or proportion of inappropriate days. There was evidence of a time-related reduction in both length of stay and inappropriate days only in the subgroup of patients with a length of stay of < 15 d. As further evidence of this period effect unrelated to the intervention, length of stay had been declining for 1 of the groups of services before this study began. We concluded that concurrent utilization review, as practiced in this study, was ineffective in the short term. However, utilization review and modification of hospital processes can reduce inefficiency, as evidenced by the time-related reduction in inefficiency illustrated in our study.

Admitting Department, Hospital↗
PubMed1999

Managed behavioral health care and supply-side economics. 1998 Carl Taube Lecture.

BACKGROUND: Within the past decade, the mental health care system in the United States has undergone a significant transformation in terms of delivery, financing and work force configuration. Contracting between managed care organizations (MCOs) and providers has become increasingly prevalent, paralleling the trend in health care in general. These managed care carve-outs in behavioral health depend on networks of providers who agree to capitated rates or discounted fees for service for those patients covered by the carve-out contracts. Moreover, the carve-outs use a broader array of mental health providers than is typically found in traditional indemnity plans, encourage time-limited versus long-term treatments and favor providers who are engaged in outpatient care. This phenomenal growth in managed behavioral health care over the past decade includes the rapid growth and quick consolidation of mental health MCOs. The period 1992-1998 shows steady and substantial annual increases in the number of enrollees in mental health MCOs, the figure more than doubling from 78.1 million people in 1992 to a projected 156.6 million in 1998, or 70% of insured lives. Moreover, these vast numbers of enrollees are becoming increasingly consolidated into a smaller number of firms. In 1997, 12 companies controlled nearly 85% of the managed behavioral health care market, with 60% of the market held by the three largest firms. STUDY AIMS: This article reviews empirical data and draws policy implications from the literature on managed behavioral health care in the United States. Starting with spending and spending trend estimates that show the average annual growth rate of mental health expenditures to be lower than that of health care expenditures in general over the past decade, the author examines utilization and price factors that may account for managed-care-induced cost reductions in behavioral health care, with special attention to hospital use patterns, fee discounting and the supply and earnings patterns of various types of mental health provider. In addition, data on staffing ratios and provider mixes of health maintenance organizations and mental health MCOs are reviewed as they reveal at least part of the dynamics of reconfiguration of the mental health work force in this era of managed care. CONCLUSIONS: As measured by changes in utilization and price, widespread application of "classic" managed care techniques such as preadmission review (gatekeeping), concurrent review, case management, standardized clinical guidelines and protocols, volume purchase of services and fee discounting appears to have led to significant cost reductions for providers of both impatient and outpatient mental health services. However, amidst a complex flux of market variables such as risk shifting, changing financial incentives and intensity of competition, not all of the reduction or slowdown in spending can be clearly and purely attributed to managed care. The data on the ongoing reconfiguration of the mental health work force are clearer in their implications: with an oversupply of all types of mental health providers, managed care has significant potential to increase the incidence of provider substitutions and spur the growth of integrated group practices. IMPLICATIONS FOR FURTHER RESEARCH: The current body of empirical and policy literature in mental health economics suggests several salient areas of follow-up. Is the proportionately greater impact of managed care on the annual growth rate of mental health care spending a temporary phenomenon or does it signal an enduring difference in the rates of increase between behavioral health care and health care in general? Beyond industry downsizing, what are the substitutions among mental health providers that are going on, and will go on, to produce cost-effective practices? What are the new financial or risk-sharing arrangements between providers and MCOs that will produce appropriate and high-quality mental health services?

Journal Article↗
PubMed1988

Managing the medical record on a concurrent basis: facts and possibilities.

In 1987, six Yale graduate students set out to study the concurrent review methods used in key hospitals across the US. They examined the advantages and disadvantages of concurrent review and the tie-in of medical record concurrent review coding with utilization review activities. The first part of their report is published this month, with the conclusion appearing next month.

Abstracting and Indexing↗
PubMed1988

Managing the medical record on a concurrent basis: facts and possibilities. Part 2.

In 1987, six Yale graduate students set out to study the concurrent review methods used in key hospitals across the US. They examined the advantages and disadvantages of concurrent review and the tie-in of medical record concurrent review coding with utilization review activities. The first part of their report appeared in the May issue of JAMRA. The second part appears below.

Abstracting and Indexing↗
PubMed1999

Effects of health care cost-containment programs on patterns of care and readmissions among children and adolescents.

OBJECTIVES: This study examined the effects of a utilization management program on patterns of medical care among children and adolescents. METHODS: From 1989 through 1993, the program conducted 8568 reviews of pediatric patients, ranging in age from birth to 18 years. The program used preadmission and concurrent review procedures to review and certify patients' need for care. This study used multivariate analyses to assess changes in the number of days of inpatient care approved by the program and to determine whether limitations imposed on length of stay affected the risk of 60-day readmission. RESULTS: Concurrent review reduced the number of requested days of inpatient care by 3.2 days per patient. Low-birthweight infants and adolescent patients with depression or alcohol or drug dependence accounted for a disproportionate share of the reduction. Patients classified as admitted for medical or mental health care and whose stay was restricted by concurrent review were more likely (P < .05) to be readmitted within 60 days after discharge. CONCLUSIONS: By limiting care through its review procedures, the utilization management program decreased inpatient resource consumption but also increased the risk of readmission for some patients. Continued investigation should be conducted of the effects of cost-containment programs on the quality of care given to children and adolescents, especially in the area of mental health.

Adolescent↗
PubMed2000

Drug-nutrient interactions: a review.

Concurrent administration of medications and nutrients can lead to interactions that change the absorption or metabolism of the medication or nutrient. Some of these interactions have little or no impact on the patient while others may be fatal. The objective of this article is to review the mechanisms of various drug-nutrient interactions. Topics to be discussed include specific populations at risk of interactions, nutrients that have a positive and negative effect on drug absorption, nutrients that result in alterations of drug metabolism, and a variety of pharmacologic interactions of medications with nutrients. It is vital that healthcare providers are familiar with drug-nutrient interactions and continue to educate themselves and their patients to optimize the effectiveness and minimize the toxicities of medications.

Anticoagulants↗
PubMed1990

Hospital-based utilization management: a cross-Canada survey.

Utilization management attempts to measure, understand and, when appropriate, reduce hospital use. We conducted a telephone survey to determine the status of utilization management in Canadian hospitals. The sample comprised a random selection of 30% of acute-care hospitals with over 100 beds for adults in Ontario and Quebec and all such hospitals in the other provinces. Of the 123 chief executive officers contacted 99 (80%) claimed to have a utilization management program. Of those, 90 (91%) agreed to participate in an in-depth survey or to designate a senior administrator to be interviewed who was most knowledgeable about the program. High occupancy rates and funding issues were the most common environmental triggers for the development of utilization management programs; funding issues were listed more frequently by respondents in Ontario than by those elsewhere (p = 0.0008). Retrospective review alone was used in half of the hospitals, concurrent review or some mixed approach being used in the other half. Ontario and the Atlantic provinces were more reliant than the rest of the country on retrospective review alone (p = 0.0032). Most of the hospitals used peer review and education to stimulate corrective action. Of the respondents 67% indicated that the medical staff supported the utilization management program, and 53% reported that the program had a positive impact on the relationship between administrative and medical staff. Most of the respondents were unsure of the program's impact on the quality of care or the rate of unnecessary hospital admission. However, retrospective review alone was found to be less successful in reducing inappropriate utilization than either concurrent review or combined review (p = 0.0048).

Adult↗
PubMed2002

Concomitant Graves' disease and primary hyperparathyroidism: the first case report in mainland of China and literature review.

Concurrent Graves' disease and primary hyperparathyroidism in the same patient is rare, probably accounts for hypercalcemia in no more than 1 percent of thyrotoxic patients. Hypercalcemia may be noted during the course of hyperthyroidism in as many as 22 percent of cases. The cause of hypercalcemia in a thyrotoxic patient might be due to the activation of osteoclastic bone resorption by the excess thyroid hormone, as the severity of hyperthyroidism correlates positively with osteoclastic activity in trabecular and cortical bone. In 1936, Noble JF et al reported the first case in the world. To our knowledge, only 49 such cases have been described in the literature until the year of 1989. No case has been reported again afterward. The occurrence of hypercalcemia in a patient with hyperthyroidism may present a challenging diagnostic problem. In this communication, we described the first case in mainland of China with hypercalcemia caused by concurrent hyperthyroidism and primary hyperparathyroidism, and the clinical and laboratory characteristics were studied before and after therapy with anti-thyroid medication.

Female↗
PubMed1991

The impact of Blue Cross and Blue Shield Plan utilization management programs, 1980-1988.

This study evaluates the aggregate and temporal impact seven Blue Cross and Blue Shield Plan utilization management (UM) programs have on hospital utilization and payments over a nine-year period, 1980 through 1988. The impact of these programs is determined using a statistical model that controls for variations in organizational characteristics of 56 Blue Cross and Blue Shield Plans, the health care market of the individual Plan, and several state and federal health care regulations. The statistical results indicate that over the entire period 1980 to 1988, preadmission certification, concurrent review, and denial of payment (as a part of the retrospective review program) programs were associated with lower hospital admissions, and fewer inpatient days and payments per 1,000 members. Mandatory second surgical opinion did not have a statistical impact on hospital utilization and payments. The aggregate reduction in hospital payments for all Blue Cross and Blue Shield Plans with both a preadmission certification and concurrent review program was estimated at $2.55 billion in 1988 dollars. For those Plans conducting preadmission certification, concurrent review, denial of payment, and case management programs in 1988, the total per enrollee reduction of inpatient payments was $52.94.

Blue Cross Blue Shield Insurance Plans↗
PubMed1981

Blue Cross market share, economies of scale, and cost containment effort.

This paper examines two components of the hospital insurance market structure-market share and the absolute number of enrollees in Blue Cross plans-to ascertain whether market structure affects the willingness of Blue Cross plans to use cost control measure. Empirical estimates show that larger plans are more likely to use prospective reimbursement, pre-admission testing, and concurrent review. Market share, however, has a positive effect only on concurrent review. We suggest that there are economies of scale to cost control efforts, but that high market share generally does not lead to increased cost-consciousness.

Blue Cross Blue Shield Insurance Plans↗
PubMed1980

Utilization review altered to advantage.

PSRO adopted a methodology in which first five days of hospitalization were exempted from utilization review. Substantial savings and expanded concurrent review resulted.

Concurrent Review↗
PubMed1990

The effects of positive incentive programs on physician chart completion.

It seems evident that both concurrent review programs and positive incentive programs have been implemented by a number of facilities in which little, if any, monitoring has occurred. Only half of the hospitals performing concurrent analysis provided statistics concerning the percentage of daily discharges arriving in the medical record department complete. Only one fourth of the hospitals provided information concerning the number of incomplete and delinquent medical records before and after the implementation of concurrent review. These data underscore the need for medical record administrators to evaluate the effectiveness of various strategies used to improve completion of medical records. Likewise, only a few of the hospitals that have implemented an incentive program for chart completion were able to provide all of the requested statistics concerning their chart status prior to and following the implementation of their programs. The results of the study indicate that numerous innovative procedures have been implemented in hospitals, with varying degrees of impact on the number of incomplete and delinquent medical records. The use of positive incentive programs in conjunction with punitive action is effective in helping to reduce the number of incomplete medical records.

Concurrent Review↗
PubMed2000

Patients' and providers' perceptions of outpatient treatment termination in a managed behavioral health organization.

OBJECTIVE: A common complaint about managed care is that treatment decisions of patients and providers are frequently altered by concurrent review of ongoing outpatient treatment. The objective of this study was to examine this perception from the perspectives of patients and providers. METHODS: A total of 190 patients and their providers were surveyed about the reason that outpatient treatment was terminated. The sample was randomly drawn from completed outpatient treatment episodes of a large national managed behavioral health organization. RESULTS: In more than three-quarters of the cases, outpatient treatment ended because patients and providers agreed that treatment goals were partially or completely met. Only 5 percent of patients and 3 percent of providers said that treatment ended because the managed care organization denied ongoing treatment. Agreement between patient-provider pairs was generally poor regarding the perceived reason for termination, except when termination was attributed to concurrent review by the managed behavioral health organization. CONCLUSIONS: In this study of a single large managed behavioral health organization, outpatient treatment was most likely to end based on the decisions of patients and providers rather than utilization review decisions.

Adult↗
PubMed2000

Utilization management in a large managed behavioral health organization.

OBJECTIVE: The utilization management process of a managed behavioral health organization was examined to determine the frequency and types of reviews and the extent to which rationing of service was achieved through the denial of services. METHODS: A case study of the utilization management program of a large managed behavioral health organization was done. Information was gathered from claims for 1997, and utilization review data were drawn from 51 plans. Data were examined by review type and authorization actions. RESULTS: The utilization management program performed a total of 9, 639 reviews. The most common type was concurrent review for additional outpatient therapy visits (46 percent). The second most common type was concurrent facility review (12.9 percent). The vast majority of authorizations were approved at the level requested by the provider (91.8 percent). Very few services were denied (.8 percent) or approved at a level lower than requested by the provider (1.3 percent). CONCLUSIONS: Although concerns have been raised about the high denial rates of utilization management programs, this study found very low denial rates. Further studies are needed to determine the precise mechanisms used in utilization management programs to control utilization. In addition, the large number of reviews raises questions about the time and opportunity costs of the review process.

Behavior Therapy↗
PubMed1986

Multicentre trial of four strategies to reduce use of a radiological test.

The Royal College of Radiologists' guidelines on the use of pre-operative chest X-rays were implemented for 1 year in four hospitals in England and Wales. The strategies adopted were: (1) the appointment of a utilisation review committee; (2) getting feedback on use to consultants; (3) the introduction of a new chest X-ray request form; or (4) the concurrent reviewing of chest X-ray requests by the radiology department. The lowest level of use (8.5 pre-operative chest X-rays per 100 elective operations) was achieved with the utilisation review committee after it displayed the guidelines in surgical wards. Information feedback produced a consistent reduction from 29.4 to 13.3 X-rays per 100 operations. Both the new request form and concurrent review had a moderate and intermittent effect. No change in practice occurred in a control hospital.

England↗
PubMed1993

Decision support for concurrent utilization review using a HELP-embedded expert system.

Utilization Review is the process of evaluating the efficiency of medical care, based on examination of the patient record. At LDS Hospital, the electronic patient record is in an advanced state. This paper describes the development and knowledge base verification of ASSURE (Automated Support System for Utilization Review), an application within the HELP hospital information system. ASSURE applies the Appropriateness Evaluation Protocol (AEP) Day of Care criteria to the electronic patient record, concurrent with the patient's stay. In blinded trials, an experienced Utilization Manager agreed with 92% of ASSURE's decisions on single AEP criteria for 560 acute care patients. Agreement was statistically significant, with kappa = 0.84, P < 0.0001.

Computer Systems↗