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PubMed1978

Use, costs, and quality of medical services: impact of the New Mexico peer review system. A 1971-1975 study.

To assess the effect of areawide peer review (such as that conducted by Professional Standards Review Organizations [PSROs]) on use, cost and quality of medical services, we evaluated 4 years of data on the efforts of the New Mexico Experimental Medical Care Review Organization in reviewing medical services for the Medicaid population. Utilization review had no demonstrable impact on hospital use; hospital days per 100 eligible persons rose 5.0% and 43.4% for persons enrolled all 4 years in Aid to Families with Dependent Children (AFDC) and Aid to the Permanently and Totally Disabled, respectively. Peer review produced no net dollar savings; over 4 years, the amount paid for all services per AFDC-eligible person rose 85%. Peer review improved the quality of ambulatory care through large reductions (75%) in medically unnecessary injections. If these findings are replicated elsewhere, they suggest that the goal of the PSRO program to control costs by curtailing utilization may be difficult to achieve, the quality of care goal may be pursued successfully, and the PSRO mission should be focused more on the latter.

Ambulatory Care↗
PubMed2000

Does managed care mean more hassle for physicians?

Using the results of a 1995 nationally representative survey of physicians, this paper examines the relationship between exposure to managed care and resources expended by physicians on administrative and insurance matters. Our measures of managed care exposure are the degree to which a physician experiences a variety of managed care techniques (i.e., utilization review, capitation payment, restricted panels, gatekeepers, discounted fees, compensation links to utilization measures, profiling, protocols, and salary payment). Physicians report expending, on average, three hours per week on insurance-related matters and 4.8 hours per week on administration. Although managed care techniques affect administrative and insurance-related burdens, the direction of that effect varies according to the form that managed care exposure takes. With the exception of being salaried, none of our variables has an economically significant effect on physicians' administrative/insurance burdens, even at the outer-most edge of the 95% confidence interval. Overall, our findings contradict the widely held notion that managed care dramatically raises the administrative and insurance burden of physicians.

Attitude of Health Personnel↗
PubMed1989

Utilization management in the small group insurance market.

Small businesses are the most rapidly growing segment of the economy, providing one half of all jobs in the United States. The health insurance industry must address issues which are unique to this market. The health insurance product for small businesses must have simple administration for the owners and easy access to quality medical care for the employees. Small businesses have been adversely affected by the high cost of health care. Numerous studies have shown that a major factor contributing to the high cost of health care is inappropriate and unnecessary utilization of health care. Until recently, techniques of utilization management have been difficult to adapt to the small group market. The Celtic Life Insurance Company has been using a managed care fee for service arrangement for the past three years. Celtic has been able to tailor a program for small businesses and maintain complete administrative coordination, instead of contracting with a private utilization review company. Our program maintains freedom of choice of providers and easy access to health care, without limiting access to specialists. Cost containment features have assisted insureds in selecting appropriate health care, in the appropriate setting while not interfering with the doctor-patient relationship.

Economic Competition↗
PubMed1991

Trends in utilization management: legal implications for health records administration.

Utilization management will continue, under whatever label or within whatever framework, to demand the attention of records administrators. Since all quality and utilization review is ultimately based on the data in the medical record, the role of health record administrators is central to this activity. As programs and requirements continue to evolve, successful health care providers will draw on educated records professionals to assist in successful management strategies.

Cost Control↗
PubMed1976

Socio-economics of allergy.

The Medicare (Title XVIII) program in 1965 began a new era in American medicine. For the first time medical utilization review committees began to monitor medical care. Professional standards review organizations (PSRO's) will not determine if medical care is necessary, up to standards and the most economical. The National Health Planning & Resources Development Act, signed into law in January, 1975, will perform health planning, health regulation and resource development. A National Health Insurance Plan, when passed, will combine all government health agencies into one with complete control of American medicine. This article emphasizes the need for the physician (allergist) to be aware of what is going on and how he should cope with the problems with which he will be faced.

Delivery of Health Care↗
PubMed1992

Controlling overservicing by physicians: review of office practices in Manitoba.

The Manitoba Medical Review Committee is a peer review body that monitors the patterns of practice of the province's 1800 physicians in order to prevent and control overservicing. This study examined the effectiveness of the committee in reducing the unnecessary use of complete examinations, regional examinations, special calls, nursing-home visits and diagnostic testing. In 1983-84 the practice patterns of 44 physicians were reviewed because of the higher than average volumes of services. By the end of 1987-88 the number of services per 100 patients dropped. In most cases the decrease was not offset by increases in other services or in the number of patients. The estimated savings resulting from the utilization review amounted to more than $2 million during the 4-year period.

Cost Savings↗
PubMed1995

Appropriateness of hospital use in the United Kingdom: a review of activity in the field.

OBJECTIVE: This paper reviews experience, in both research and application, with measures of appropriateness applied to the utilization of hospital inpatient services in the UK. BACKGROUND: The evolution of different methods for measuring appropriateness of use and the associated reasons for misutilization are described. RESEARCH AND APPLICATION: Recent research developments and applications are outlined and discussed. CONCLUSION: Contemporary enthusiasm with "Diagnosis Independent Explicit Criteria Utilization Review Instruments" is observed and some of the underlying influences are explored.

Health Services Research↗
PubMed1996

Detection and classification of inappropriate hospital stay.

OBJECTIVE: To study the reliability and validity of concurrent review of hospital-bed utilization carried out by a trained nurse. DESIGN: Analysis of interrater reliability and validity of utilization review. SETTING: Tertiary care hospital associated with a university. PATIENTS: Eighty patients randomly selected from 203 patients admitted to the hospital. INTERVENTIONS: Appropriateness of days of stay in hospital was classified prospectively, on the basis of clinical judgement, by two nurses working independently, by a third nurse working with the Appropriateness Evaluation Protocol (AEP) and by a multidisciplinary review panel of nurses and physicians working retrospectively with the use of data gathered by the first nurse. MAIN OUTCOME MEASURES: Agreement between different rates on the number of and reason for inappropriate admission days, total number of inappropriate days and of inappropriate days due to delayed discharge, to diagnostic procedures or to inefficient medical management. RESULTS: Agreement between the two nurses who used clinical judgement was substantial (kappa or the intraclass correlation coefficient [RI] 0.77 to 0.98 on the number of and reason for inappropriate admission days, on the total number of inappropriate hospital days and on days due to delayed discharge, diagnostic procedures or inefficient medical management. Agreement was moderate (RI 0.47) on the number of inappropriate day's stay awaiting surgery. Agreement was substantial (kappa or RI 0.69 to 0.94) between the two nurses who used clinical judgement and the panel, except on the total number of inappropriate days; however, for this variable, exclusion of one case increased the RI from 0.35 to 0.80. Agreement was substantial between the two nurses who used clinical judgement and the nurse who used the AEP on appropriateness of admission days and the number of inappropriate days. Agreement between the panel and the nurse who used the AEP on the number of inappropriate days rose from 0.36 to 0.88 when the one outlying case was excluded. Some admissions were classified as premature when the AEP was used, whereas other raters considered the admissions unnecessary. There was poor agreement between the nurse who used the AEP and the other raters on the number of inappropriate days' stay awaiting surgery or diagnostic tests. CONCLUSIONS: Data collection and judgement of appropriateness of hospital stay by a trained nurse is feasible and reliable. A nurse working prospectively and a panel working retrospectively sometimes disagree. The AEP provides a similar estimate of the number of inappropriate days but may be insensitive to patient factors that influence the timing of admission.

Female↗
PubMed1982

Analyzing inpatient hospital duration and intensity: a methodology.

As a complement to a number of existing cost-containment programs, Blue Cross of Maryland developed a length of stay (LOS) review process for its members. The method is based on the premise that the utilization of hospital inpatient services varies along two major dimensions--service duration (expressed in days of hospital stay) and service intensity (expressed as the proportion of ancillary service charges to total charges). Composed of seven steps, the method statistically analyzes the relationship between LOS and ancillary service charges as a proportion of total charges for selected diagnoses. The attempt to monitor two dimensions of inpatient care simultaneously is a departure from existing utilization review methods. Besides a detailed description of each step in this methodology, this article presents preliminary findings from a pilot study conducted in eight Baltimore hospitals.

Costs and Cost Analysis↗
PubMedDate not supplied

Determining physicians' knowledge and attitudes when prescribing drugs to treat gastrointestinal disorders.

OBJECTIVE: Peptic ulcer disease (PUD) affects 10% to 15% of the US population. The causes of PUD are many, including high acid production, low bicarbonate secretion, and infection due to Helicobacter pylori. In 1992, the Vermont Medicaid Program noted a significant increase in prescription drug expenditures, particularly in the area of treatment of PUD. The purpose of this study was to review Medicaid prescription data and to use focus group methodology to gain an understanding of rural nonacademic and semiurban academic physicians' prescribing decisions regarding the treatment of PUD. METHODS: Pharmaceutical data from 1991 and 1992, provided by the Department of Social Welfare, Medicaid Division, was reviewed. Focus group discussions were held with primary-care providers from rural and semiurban regions with Vermont. RESULTS: Pharmaceutical review revealed that expenditures increased 21% for gastrointestinal drugs from 1991 to 1992. Drug utilization review of pharmaceutical prescriptions revealed that H2 antagonists were being prescribed for greater than the recommended 6 to 8 weeks in 60% of the cases. Focus group discussions showed that rural nonacademic and urban academic physicians had similar concerns and management plans in regard to their patients with peptic ulcer disease. However, differences existed in physician perceptions regarding pharmaceutical effectiveness of various agents for the treatment of PUD. CONCLUSIONS: Physician education outreach programs should be designed to standardize treatment methodology for PUD throughout the state. This standardization of treatment could have a significant impact on healthcare costs and the ease with which patients can eradicate this disease.

Clinical Competence↗
PubMed1992

Determining medical necessity of outpatient physical therapy services.

A patient referred for physical therapy may attend one or several therapy visits or may continue to receive ongoing therapy services several times weekly for several months. The question of the continued medical necessity of those services arises often. Determination of medical necessity for continued therapy services requires knowledge of the natural history of diseases that may require therapy services, familiarity with the effectiveness of treatment alternatives for those diseases, and awareness of community practice patterns. Accurate and complete documentation from the therapist or referring physician is required for the physician advisor or utilization review consultant to make an accurate determination of medical necessity. A structured format for providing this documentation is suggested.

Adult↗
PubMedDate not supplied

The critical role of ERISA in state health reform.

Despite prominent roles for employers and state regulation in the Clinton administration's Health Security Act, relatively little attention has been accorded to the impact of federal preemption of state legislation through the Employee Retirement Income Security Act (ERISA). As interpreted by the U.S. Supreme Court, ERISA permits state regulation of insured employee health plans but otherwise preempts analogous regulation relating to self-insured benefit plans. This has prompted lower courts to find that hospital rate-setting legislation, regulation of preferred provider organizations (PPOs), and medical malpractice suits for utilization review decisions are preempted by ERISA. Several issues with major implications for health reform remain unresolved, such as the availability of ERISA preemption to self-insured health alliances and health maintenance organizations (HMOs).

Health Benefit Plans, Employee↗
PubMed1994

Integrating case management and utilization management.

Over the years the utilization review coordinator's role has evolved to more than quality assessment, risk management, and utilization management. Recognizing the need to expand the traditional role, one hospital integrated two positions: case management and utilization management. A 2-mont pilot defining roles, responsibilities, outcomes, and future goals is described.

Hospitals, Religious↗
PubMed1994

Information technology enters the doctor's office: Part II--Six lessons about intended ... and unintended ... results.

Part I of this article ("Six Design and Implementation Lessons," Physician Executive, Sept.-Oct. 1993, pp. 46-50) described an ambulatory utilization review (AUR) program designed and implemented by Metropolitan Life Insurance Company and reviewed some of the lessons learned over the past five years. Those lessons pertained to the tasks of inventing a new information technology to measure and evaluate ambulatory care and some of the practical implementation issues associated with review of 30,000 small dollar value claims per day in 19 claim offices nationwide. This article turns to the basic purpose of AUR--to review the medical necessity and appropriateness of ambulatory utilization. One lesson learned about AUR in this context is that AUR works: savings from the program outweigh costs by almost 5:1. The more important lessons, however, stem from understanding how the savings are achieved, and what some of the other unintended benefits of the program are.

Ambulatory Care↗
PubMed1987

The psychiatric, alcohol, and drug algorithm: a decision model for the nurse reviewer.

Although preadmission review and concurrent review are useful tools for limiting unnecessary medical expenditures, psychiatric and chemical dependency cases are more difficult to assess than medical/surgical cases because they are described in relatively subjective terms and do not lend themselves to review by systems currently in use. The Psychiatric, Alcohol, and Drug Algorithm (PADA) is a straightforward utilization review system for these cases. PADA is organized in decision trees for each reason for admission and reason for continued stay; this system enables nurse reviewers to make recommendations on most cases without further review.

Algorithms↗
PubMed1995

Using Medicaid fee-for-service data to develop community health center policy.

This article presents an analysis of fee-for-service Medicaid data for King County, Washington. This analysis was conducted using Department of Social and Health Services billing records for patients of the community health centers of Seattle-King County (14 primary care sites), the Seattle-King County Department of Public Health (9 primary care sites), and Harborview Medical Center (a large tertiary facility with a primary care outpatient clinic associated with the University of Washington) from January through June, 1992. The complete billing records of all patients who utilized any one of the 24 sites were made available. These records were used to review utilization patterns and patient costs. The implications for community health centers regarding Medicaid managed care, health care reform, and population-based management are discussed.

Aid to Families with Dependent Children↗
PubMed1989

Regional blood usage review: a quality assessment study from New Jersey hospitals.

In 1986, the American Red Cross/New Jersey Blood Service (NJBS) conducted a blood utilization review of the use of red blood cells (RBCs), platelets, and fresh frozen plasma (FFP) in nine hospitals in the NJBS region. The director of NJBS analyzed the collected data and categorized the justification criteria for blood transfusion. Their study found that female patients and patients over 60 years of age are the largest users of blood products, the average number of RBC units used is three, and the most common indication for RBC use is hypovolemia due to surgery. There was a high degree of compliance with justified criteria of use for RBC transfusion, although platelet and FFP use and pretransfusion nursing documentation require improvement.

Blood Transfusion↗
PubMed1991

The cost of monitoring medical care in Pennsylvania.

We estimated the cost of the Health Care Cost Containment Act in Pennsylvania to be over $19 million; the yearly direct cost of KePRO activities to be over $14 million; and compliance costs for peer review to possibly be as large as $27 million, based on our high estimate. We also found that medical records, utilization review and administrative departments in Pennsylvania hospitals have collective annual budgetary expenditures of close to $2.4 billion. In addition, we estimated Pennsylvania physicians to spend from $14 million to $17 million each year on administrative and fiscal activities related to reimbursement. Our cost estimates for non-clinical expenditures were based on the best data available at the time, though in many cases this data was crude. However, we believe that this data is a useful starting place for a dialogue about the cost and effectiveness of these programs. In reporting the cost of these activities it was not our intent to judge the value of any individual program. Instead we hope that we have taken a first step in the process of collecting cost data so that actual costs for non-clinical activities can be appropriately evaluated. Future studies of non-clinical expenditures should not only include direct program expenditures but also the economic impact on providers in complying with the mandates. Finally, efforts to reduce duplicate and unproductive regulatory programs will be necessary in working toward a cost-efficient system. Legislative efforts, such as the Physician Regulatory Relief and Improvement Act (H.R. 4475 and S.B 2051), aimed at the so called "hassle factor" will be helpful.

Cost Control↗