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Although managed health care is increasing exponentially in the United States, minimal published information exists regarding the human resources needed to perform various managed care activities. This article reports on the results of a national survey of managed care organizations regarding the quantitative use of nurse and physician reviewers and the type of activities being performed.
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OBJECTIVE: To evaluate the impact of managed care on the use of chronic disease medications. DATA SOURCE: Claims data from 1997 from two indemnity and three independent practice association (IPA) model managed care insurance plans. RESEARCH DESIGN: Cross-sectional analysis of claims data. DATA COLLECTION: Adult patients with diabetes mellitus (DM, n = 26,444), congestive heart failure (CHF, n = 7,978), and asthma (n = 9,850) were identified by ICD-9 codes. Chronic disease medication use was defined through pharmacy claims for patients receiving one or more prescriptions for drugs used in treating these conditions. Using multiple logistic regression we adjusted for patient case mix and the number of primary care visits. PRINCIPAL FINDINGS: With few exceptions, managed care patients were more likely to use chronic disease medications than indemnity patients. In DM, managed care patients were more likely to use sulfonylureas (43 percent versus 39 percent for indemnity), metformin (26 percent versus 18 percent), and troglitazone (8.8 percent versus 6.4 percent), but not insulin. For CHF patients, managed care patients were more likely to use loop diuretics (45 percent versus 41 percent), ACE inhibitors or angiotensin receptor blockers (50 percent versus 41 percent), and beta-blockers (23 percent versus 16 percent), but we found no differences in digoxin use. In asthma, managed care patients were more likely to use inhaled corticosteroids (34 percent versus 30 percent), systemic corticosteroids (18 percent versus 16 percent), short-acting beta-agonists (42 percent versus 33 percent), long-acting beta-agonists (9.9 percent versus 8.6 percent), and leukotriene modifiers (5.4 percent versus 4.1 percent), but not cromolyn or methylxanthines. Statistically significant differences remained after multivariate analysis that controlled for age, gender, and severity. CONCLUSIONS: Chronic disease patients in these managed care plans are more likely to receive both inexpensive and expensive medications. Exceptions included older medications partly supplanted by newer therapies. Differences may be explained by the fact that patients in indemnity plans face higher out-of-pocket costs and managed care plans promote more aggressive medication use. The relatively low likelihood of condition-specific medications in both plan types is a matter of concern, however.
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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.
In a recent appellate court decision, a practitioner was granted the right to challenge a claims denial under provisions of the Employee Retirement Income Security Act of 1974. This article reviews the reasoning of the court in allowing the practitioner standing in the court under ERISA and reviews the language of the insurance contract that led the court to affirm denial of payment to the practitioner. "Health Law" is a regular feature of Physician Executive contributed by Epstein Becker & Green. Mark E. Lutes of the law firm's Washington, D.C, offices serves as editor for the column.
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The National Association of Insurance Commissioners (NAIC) Medical Malpractice Closed Claim Study 1975-1978 is the first major uniform nationwide survey of its kind. A total of 71,782 closed claims were reviewed during a 3 1/2-year period. Approximately one third of these claims involved indemnity payments. A review of the dermatologic closed claims with indemnity payments included in the study revealed that dermatologists accounted for 127 claims representing 0.7% of total paid claims, with payments totaling +2,549,125 representing 0.6% of total indemnity dollars paid. Since our specialty represents 1.4% of all practicing physicians, it is clear that the NAIC study reaffirms dermatology as being among the lowest malpractice risk specialties.
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.
The part B medical review methods currently used by Medicare carriers to control resource use suffer from a series of problems including failure to reward deterrence of unnecessary claims, failure to detect substitution of nonreviewed claims, reliance on average rather than marginal measures of performance, excessive focusing of reviews, and the inability to measure effectiveness separately from the intervention. This article describes these problems and proposes a series of alternative strategies for review that may improve these problems.
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Businesses are beginning to take more of an interest in the way some states are regulating utilization review firms. Employers complain that provider-backed laws are restricting the use of utilization review, a key tool in containing healthcare costs.
Home health organizations seeking to improve the performance of their accounts receivable should concentrate first on establishing practices that promote the greatest percentage of clean claims and reviewing payments received to be sure rates paid are optimal. They also may find it worthwhile to survey their business office operations for potential improvements to key areas.
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OBJECTIVES: To ascertain the extent of the use of acupuncture and the characteristics of general practitioners using acupuncture. DESIGN: Secondary analysis of 1996 Health Insurance Commission data on claims by all non-specialist medical practitioners for Medicare Benefits Schedule items for an attendance where acupuncture was performed by a medical practitioner. MAIN OUTCOME MEASURES: Use of acupuncture by general practitioners and the practitioners' sex, age, place of primary medical qualification, and the socioeconomic disadvantage index of the practitioners' practice. RESULTS: 15.1% of general practitioners claimed for acupuncture. Acupuncture was more likely to be provided by male practitioners, by those aged 35-54 years, and by practitioners who have an overseas primary medical qualification. The socioeconomic index of the practice did not significantly affect the number of claims for acupuncture. CONCLUSION: Acupuncture is used by about one in seven general practitioners. Its use is associated with middle-aged practitioners, who presumably have more clinical experience. This level of use by experienced doctors suggests that a critical review of the appropriate role of acupuncture in general practice should be considered.