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PubMed2002

Patients hospitalized for medical conditions in Winnipeg, Canada: appropriateness and level of care.

A medical record review of patients hospitalized for medical conditions in Winnipeg, Canada during 1998/99 was completed using InterQual utilization review instruments. On admission, 95% of patients required the services provided in an acute care facility. Fifty-eight percent of days in hospital following the day of admission required an acute care setting, and 42% required an alternate level of care. Our results suggest there is room for treating more acute patients within the existing system.

Acute Disease↗
PubMed2006

Analysis of anti-epileptic drugs in fee-for-service Wisconsin Medicaid.

INTRODUCTION: Off-label use of prescription drugs presents issues of patient safety and can significantly increase the overall prescription drug expenditure in providing health care services. As a class, the anti-epileptic drugs are provided for off-label use on a frequent basis. Because of the safety issues and increased cost with such prescribing practices, the Wisconsin Medicaid Drug Utilization Review Board (DUR board) reviewed the use of anti-epileptic agents in the fee-for-service Wisconsin Medicaid population. METHODS: Prescribers with the highest amount paid for drugs in this class, and for which there was no appropriate diagnosis (intervention group), were provided with a list of the patients for whom they prescribed the drug for an off-label clinical condition. A total of 488 prescribers were contacted and informed of the costs and hazards of off-label prescribing. RESULTS: Using a comparison group of patients who were prescribed anti-epileptic agents but who did not reach the amount paid threshold (non-intervention group), the study demonstrated a decrease of 6652 prescriptions in the intervention group and an increase of 4194 in the non-intervention group. In addition, expenditures for the intervention group dropped by dollar 752,232 and the non-intervention group rose by dollar 835,351. It is estimated that the overall financial impact of this intervention was a savings of dollar 2,552,077 over the 5-month period of review.

Anticonvulsants↗
PubMed2006

What will it take for disease management to demonstrate a return on investment? New perspectives on an old theme.

BACKGROUND: Disease management programs are expected (and usually contractually required) to reduce total costs in the diseases they manage. OBJECTIVES: To discuss the appropriateness of using utilization indexes in lieu of cost and the importance of reviewing utilization trends to determine whether sufficient opportunity exists for a program to be financially effective; and to conduct an analysis to determine the number of admissions that must be reduced for a program to achieve various levels of return on investment. STUDY DESIGN: Descriptive. METHODS: Historical inpatient cost trends, discharges per 10,000 population, the mean length of stay, and emergency department visits per 10,000 population for acute myocardial infarction, congestive heart failure, asthma, and diabetes mellitus are presented. A "number-needed-to-decrease" analysis is performed to determine the number of admissions or emergency department visits that must be reduced to meet varying levels of return on investment. RESULTS: (1) Hospital days per 10,000 population for these conditions trended downward, while costs during the same period escalated. (2) Discharge and emergency department visit rates per 10,000 population were flat and low during the observation period, while the mean length of stay declined. Results of the number-needed-to-decrease analysis suggest that disease management programs will have to decrease admissions 10% to 30% to cover program fees alone. CONCLUSION: A review of historical utilization trends and a number-needed-to-decrease analysis should be conducted before disease management program implementation to determine whether sufficient opportunity exists to reduce utilization to levels that will ensure a positive return on investment.

Chronic Disease↗
PubMedDate not supplied

Effect of patient information on the quality of pharmacists' drug use review decisions.

OBJECTIVE: To evaluate the effect of incremental increases in patient information on the quality of pharmacists' clinical decisions related to legally mandated prospective drug utilization review (DUR) responsibilities. DESIGN: Unblinded comparison of two groups. PARTICIPANTS: 28 community pharmacists in Indiana (group 1) and 32 Public Health Service pharmacists employed in the Indian Health Service (IHS) (group 2). INTERVENTIONS: Clinical cases involving prescribing problems were developed from patient charts. Each case contained four levels of increasing patient information: Level 1 included only information required for a legal prescription in Indiana; Level 2 added the patient's current medication profile, age, and allergies; Level 3 added the diagnosis or reason for use of the prescribed medication; and Level 4 added the physician's progress note. Pharmacists were asked to evaluate the prescribed drug therapy at each level of each case and complete a Dispensing Appropriateness Index (DAI) report, which included all prospective DUR criteria required by the Omnibus Budget Reconciliation Act of 1990. The quality of pharmacists' DUR decisions at each level of patient information was evaluated by comparing pharmacists' responses on the DAI reports with the consensus judgment of two clinical experts. RESULTS: The quality of both community and IHS pharmacists' DUR decisions improved significantly at each incremental level of patient information. CONCLUSION: Pharmacists in this study made better decisions when they had access to more complete patient information on which to base their decisions.

Adult↗
PubMed1982

Setting resource utilization standards in a Community Mental Health Center.

Recognizing the impediments to standard setting in community mental health centers, the utilization review (UR) committee at West-Ros-Park Mental Health Center in Boston based its UR standards on clients' ability or inability to meet social and personal expectations in four areas: productivity, independent living/self-care, immediate social relationships, and extended social networks. Classifying treatment modalities into four service categories and analyzing clients' disabilities enabled the UR committee to establish practical standards for appropriate amounts and duration of services based on clients' role performance scores. Implications of this standard-setting approach are discussed, and an example of the standard-setting process undertaken in one of the facility's treatment programs is described.

Activities of Daily Living↗
PubMed2003

Methods for estimating private sector payments for VA acute inpatient stays.

OBJECTIVES: To describe methods for estimating hypothetical private sector payments for Veterans Health Administration (VA) acute inpatient stays. METHODS: We assumed all VA hospitalizations would have occurred under a hypothetical VA system that paid private sector providers but had the current benefit package for VA patients. We compared aggregate budgets for VA inpatient care (less physician salaries) at six VA hospitals over federal fiscal year 1999 to aggregated hypothetical private sector payments developed using VA diagnosis-related groups matched to metropolitan-based average Medicare payments. Counts of care came from the VA's statistical analysis system (SAS) inpatient files. Inpatient stays with both medical or surgical and psychiatric or rehabilitation care were counted as two stays. An external auditor conducted three reviews of VA coding practices during the study year, and the appropriateness of admissions was examined using a commercial utilization review tool. RESULTS: For 30,518 inpatient discharges, hypothetical payments were $188 million, compared with the VA budget of $171 million. Fifteen of the 25 most frequent diagnosis-related groups in the VA were also in the top 25 for Medicare in 1998 and 1999. Audits established that the overall financial impact of VA coding problems was similar to that in the private sector. DISCUSSION: Differences in organization, practice, and incentives limit estimates of the financial impact of shifting VA acute inpatient care to the private sector.

Budgets↗
PubMed1991

A psychodynamic perspective on the clinical impact of insurance review.

The rise of managed care and concurrent utilization review has had a profound impact on the practice of inpatient psychiatry. Little has been written, however, on the clinical impact of the review process itself. The actions of insurance reviewers often result in their being incorporated into the psychopathology of individual patients and into the dynamics of families and institutional settings. The authors apply psychodynamic understanding to a series of case examples to illustrate how concurrent review may promote splitting, impede the patient's ability to separate from the hospital, and paradoxically reinforce the patient's illness. They also explore a number of typical responses of treatment staff and families to the review process. A case vignette demonstrating a sincere effort at mutual collaboration between payers and providers is also presented. This spirit of compromise is proposed as the solution that best serves patient care.

Adolescent↗
PubMed1989

Creating the climate for effective UR.

This article, the second of two, describes the role that management and planners need to play in fostering their hospitals' development of effective utilization review programs. Among the major issues that must be addressed are whether the organization's culture is ready for utilization management and whether incentives are in place to make the system work.

Health Facility Administrators↗
PubMed1992

Realizing the potential of practice pattern profiling.

In January 1992, the Physician Payment Review Commission held a conference to learn about the appropriateness of present uses of profiling of practice patterns, and to identify what will be required to realize the full potential of this technique in the future. The conference addressed the data needs of profiling, the development of valid and relevant profiles, the impact of profiles on medical practice, and controversies surrounding public access to profiling information and the uses to which profiling has been put. This paper, based in part on that conference, reviews the basic concepts that underlie profiling and describes the roles that profiling can play in quality improvement, assessment of provider performance, and utilization review. It uses case studies to illustrate the types of problems that have arisen in actual usage and discusses what will be required to resolve them. The final section describes the roles that profiling can play in achieving the goals of health care reform, and concludes with what is needed in data and infrastructure development to improve the quality and usefulness of profiling.

Data Collection↗
PubMedDate not supplied

Information technology enters the doctor's office: Part I--Six design and implementation lessons.

Because of a trend toward increased cost escalation outside of the hospital, in the ambulatory care setting, Metropolitan Life Insurance Company initiated an Ambulatory Utilization Review ("AUR") program in 1986. This is an overview of the lessons learned since that time. Some of what was learned was simply--or not so simply--"how to," the subject of this first article in a two-part series. Once this deceptively difficult technology was understood, there were two additional categories of lessons to learn: the extent of expected program results and some unexpected results. This second set of lessons is reviewed in Part II of the article.

Ambulatory Care↗
PubMed2000

Assessment of the Massachusetts Behavioral Health Program Year 6.

After a difficult transition from the previous vendor to the Massachusetts Behavioral Health Partnership (MBHP), Year 6 was a year of stability and incremental changes for the Massachusetts Behavioral Health Program. This assessment of Year 6 is based on interviews with key players, data provided by the MBHP, a survey of providers, as well as on the fifth year of an ongoing review of the program. Results indicate that enrollment grew, and new services were developed in response to identified needs. Providers considered access, utilization, and quality of care to be the same or better than a year earlier. Coordination improved, but was not optimal. Clinical and overall decisions with MBHP were collaborative or negotiated and less hierarchical in manner than the previous year. Providers rated MBHP better than other managed care organizations on quality of care and utilization review decisions, access, flexibility, and administration.

Child↗
PubMed1999

A new physician's guide to evaluating managed care opportunities.

AUDIENCE: This article is designed for new physicians and administrators who evaluate and negotiate as providers with managed care organizations. GOALS: To provide a review of the major issues impacting on medical practices as they develop contractual relationships with managed care organizations. OBJECTIVES: 1. To review the four major types of health maintenance organizations, providing some general detail about the financial policies of each. 2. To outline how utilization review and quality assurance policies can affect individual physician practice. 3. To discuss risk-sharing arrangements employed by managed care organizations, including their financial and clinical impact, and to outline the issues a new physician should consider when evaluating a contract.

Capitation Fee↗
PubMed1994

PPOs are beginning to plug into age of automation.

As relative latecomers to the computer age, most preferred provider organizations are just beginning to see the value of automation in gaining a competitive advantage. In addition to using electronic data interchange to automate claims processing, some forward-thinking PPOs are using automation to provide quick confirmation of patient eligibility for coverage or to streamline utilization review.

Eligibility Determination↗
PubMed2004

Evaluation of angiotensin-converting enzyme inhibitor use in patients with type 2 diabetes in a state managed care plan.

OBJECTIVE: To compare angiotensin-converting enzyme (ACE) inhibitor use in patients with type 2 diabetes at 1 year and 3 years after guidelines were published. STUDY DESIGN: Retrospective database review. PATIENTS AND METHODS: The drug utilization review database of a state managed care plan was accessed to retrieve 2 random samples of 500 patients each. These patients had an International Classification of Diseases, Ninth Revision, Clinical Modification code for diabetes mellitus (250) and a National Drug Code for an oral hypoglycemic agent in both 1998 and 2000. Specific clinical modification codes, prescription claims, and diagnostic codes were obtained from patient profiles. Use of ACE inhibitors in 1998 and 2000 then was evaluated by using Pearson's chi-square test. RESULTS: The proportion of patients with diabetes and hypertension who were taking an ACE inhibitor increased by 10 percentage points over the 2 years; however, ACE inhibitors were only used in 46% of those patients in 2000. A few of the patients receiving an ACE inhibitor had a contraindication to use of the agent. Microalbuminuria screening and glycosylated hemoglobin screening were found to have been conducted in only 4.6% and 54.6%, respectively, of the 496 patients in 2000. CONCLUSIONS: The results of this study indicate that although ACE inhibitor use improved, fewer than 50% of patients received appropriate therapy. Awareness of and adherence to the recommendations in the guidelines need to be improved. Larger studies may be beneficial to determine more clearly the extent of this problem.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1994

Using an appeals panel to mediate mental health care UR disputes.

The certification of admission and lengthy psychiatric hospitalizations raises fundamental issues related to the appropriateness of treatment. The author presents several case examples to illustrate how an appeals panel resolves disputed utilization review decisions regarding inpatient psychiatric treatment.

Decision Making, Organizational↗
PubMed1999

Revenge of the reviewed.

The managed care backlash has shifted to a new target: HMO medical directors. Federal law shields employer-sponsored health plans from most state oversight and lawsuits, but angry enrollees have begun taking a back route, turning state medical boards on doctors in charge of utilization review. One attorney calls them "the soft underbelly of managed care."

Insurance Claim Review↗