Oklahoma's unique peer review system.
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Length of Stay↗
SEARCH · Search PubMed
Results for “Utilization Review”
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
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Cost containment and medical judgment.
A physician should not allow financial criteria to influence his decision to discharge a patient from the hospital despite pressures that may exist to do so. If injury to the patient is attributable to a premature discharge approved by a physician, the physician can expect to be held accountable. Under Wickline, a physician should protest to a third-party payor whose prospective utilization review decision would result in the withholding of necessary medical care. Such protests should be documented. Where a patient requires continued hospitalization, it would be advisable to so inform the patient and the hospital administrator so that arrangements for care in an appropriate facility can be made.
Adult↗
Medicare patients and alternatives to the acute care hospital.
There are many instances where hospitalized elderly patients no longer need intensive hospital care but are not ready to be discharged. One solution to this dilemma is the use of a skilled nursing facility (SNF) or some type of step-down bed, where patients can continue to receive managed care at a less intense and costly level. A major concern with using step-down beds is that while costs may be controlled, quality of care may suffer and patient outcomes may be jeopardized. From an efficiency perspective, the step-down bed can provide an excellent alternative to hospital care for the less acutely-ill patient. For alternative managed care environments to be satisfactorily received by patients and physicians, however, they must produce outcomes equal or better than those in the hospital. Some patients and diagnoses are more appropriate than others for treatment in alternative managed care environments. The judgement of appropriateness must take into account patient and physician satisfaction with the efficiency and effectiveness of the care. This paper describes how the Fallon Community Health Plan, Worcester, Mass., which regularly uses a step-down facility for patient care, assessed outcomes in terms of efficiency and effectiveness. An overview of this alternative managed care facility and its relationship to the HMO is discussed below. Several studies examining outcomes and patient and physician satisfaction are presented. Finally, the ways in which these studies represent a merger of quality assurance (QA) and utilization review (UR) methodologies are discussed.
Aged↗
OURS appears good way for peer review.
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Economics, Hospital↗
Final prospective payment rules contain important revisions.
The final rules for the first year of Medicare's prospective payment contain a number of crucial revisions of the interim rules: Payment standards. Because of a revised estimate of inflation, the adjusted federal standardized payment amounts have been reduced about $12. Update factors. Revised inflation updating factors will be applied to the hospital-specific portion of payment rates and will reflect a lower (0.1 percent) budget-neutrality adjustment. Outliers. For the three-year transitional period, additional payments for outlier patients will be based entirely on a smaller percentage of the federal payment amounts. Permissible charges to beneficiaries. Hospitals may charge beneficiaries for custodial care and medically unnecessary services before the day-outlier threshold is passed if the hospital or its utilization review committee determines that the beneficiary no longer needs inpatient care; this determination is confirmed by the attending physician or external medical review entity; and the patient is notified of the determination and potential charges. Periodic interim payment. This payment may be adjusted semiannually, or more frequently at a hospital's request. Biweekly payments will be made for items reimbursed on a reasonable-cost basis.
Diagnosis-Related Groups↗
ICD-9-CM code and coding practice changes for case mix management.
Over the past several years, there has been increased interest in the quality of existing patient data for analysis purposes. Although attempts have been made to use discharge abstract data in numerous applications, e.g., hospital planning and utilization review programs, probably the greatest impact has come with the use of these data as the basis of hospital payment for patient care services. This one application has led the health care community to pay serious attention to the consistency and accuracy of patient data collection.
Abstracting and Indexing↗
Forum: A remedy for outmoded medical education.
Director of Health and Medical Systems at a major teaching hospital and a medical educator himself, the author maintains that the current medical education system is producing physicians who are "societal and professional misfits." He sets forth a remedial action plan that stresses the interrelationships of medicine and other disciplines; quality assurance; utilization review; risk management; patient relations training; and cost containment. And he suggests that embracing, rather than avoiding, these concerns is the key to better quality of care and reduced costs.
Cost-Benefit Analysis↗
Local collaboration needed for long-term care insurance.
Private insurance may be the most viable approach to financing long-term care for middle- and upper-income elderly, but many issues must be considered. Should public policy favor service-oriented or indemnity plans? Should states require companies to offer a minimum plan benefit to sell policies? Should companies try to design integrated plans that presume future Medicaid eligibility for some private-plan enrollees? Should states and private businesses require professional quality review, utilization control, and cost management features? One policy direction would encourage local management of insured individuals' long-term care, but such a strategy should be tested for structural, technical, administrative, and financial feasibility. A local management structure for long-term care insurance would have four functions: expenditure control, utilization control, quality control, and service development.
Aged↗
Factors affecting Medicaid patients' length of stay in psychiatric units.
The structure of the Medicaid program varies widely among the States. Examined in this article is the relationship between certain characteristics of the State Medicaid programs and the length of stay of patients who are discharged from psychiatric units in general hospitals. It has been found that setting limits on the number of reimbursable days leads to shorter lengths of stay and that, after controlling for region, length of stay is not influenced by utilization review or State rate setting.
Adolescent↗
Conventional health insurance: a decade later.
In this article, the 1987 conventional health plans are examined and 1987 group health insurance is compared with that of 1977. The source of information for 1987 is the national survey of 771 private and public employers conducted by the Health Insurance Association of America. Data for 1977 are from the National Medical Care Expenditures Survey. Findings show that conventional health plans' share of the group market declined from 95 to 73 percent during the decade; the majority of Americans covered by conventional group insurance are now enrolled in a plan that self-insures; prospective utilization review grew dramatically after 1984; and patient cost sharing increased, but not as significantly as conventional wisdom holds.
Data Collection↗
Does your hospital need a full-time physician manager?
Full-time medical administrators are leaving their mark on health care administration. As the physician member of the hospital's top management team, the vice-president for medical affairs has a major impact on quality assurance efforts, utilization review, risk management, and strategic planning.
Medical Staff, Hospital↗
Survey search: prevalence/effects of newer mental health care and cost management programs.
Three types of programs are beginning to capture the imagination of employers concerned about issues related to mental health care and its costs: utilization review, particularly via psychiatric PPOs and case management; Employee Assistance Programs; and substance abuse testing. The spread of these programs, the promise and problems they present and their effectiveness (where measured on a wide scale) are documented here, based on studies by a variety of researchers.
Data Collection↗
Pennsylvania PHO chooses mission and cuts costs.
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Capitation Fee↗
Features of employment-based health plans.
This Issue Brief focuses on changes to the health care financing and delivery system as implemented by employers. It discusses health plan costs, cost sharing, plan funding, health care delivery systems, services covered under various health plan types, coverage limitations, and retiree health coverage. National health expenditures are estimated at $1.035 trillion, representing 13.6 percent of Gross Domestic Product in 1996, up from $699.5 billion and 12.2 percent in 1990. Rising health care spending is also evident at the employer level: In 1996, employer spending on private health insurance totaled $262.7 billion, up from $61.0 billion in 1980. Business health spending as a percentage of total compensation increased from 3.7 percent in 1980 to a high of 6.6 percent in 1993, and declined to 5.9 percent in 1996. Employment-based health plans are the most common source of health insurance coverage among the nonelderly population in the United States, providing coverage to nearly two-thirds of those under age 65. Despite the growth of many cost-sharing provisions, individuals are paying a smaller percentage of total health care costs. In 1960, 69 percent of private health care expenditures were paid out of pocket. Between 1993 and 1996, only 37 percent of private health expenditures were paid out of pocket. One of the most significant developments of the 1980s, which has continued throughout the 1990s, is the growth of managed care plans. As recently as 1994, traditional indemnity plans were the most commonly offered type of employment-based health plan. As fewer employers offered traditional indemnity plans, participation in these plans declined and participation in managed care plans increased. In 1997, 15 percent of employees participating in a health plan were enrolled in an indemnity plan, compared with 52 percent in 1992. Since 1993, employment-based health benefit cost inflation has been virtually nonexistent. Employers have kept cost increases low by using managed care and making other changes. Workers have been shifted to, have been induced to choose, or have voluntarily selected managed care health plans. Preferred provider organization (PPO) and point-of-service (POS) plans have experienced relatively strong gains in enrollment. Employers have also increased the use of utilization review for active workers, and cut back on health benefits for retirees. These changes are in stark contrast to the pre-1993 period, which saw even faster change, with rising health care costs and increasing deductibles and coinsurance for workers in non-HMOs.
Cost Sharing↗
[Assessment of the need for and length of hospitalization at the internal medicine department].
We used the Appropriateness Evaluation Protocol (AEP) to evaluate appropriateness of admission and continuing hospitalization (daily till discharge of maximally till 15th day of hospitalization) of 260 patients admitted consecutively to department of internal medicine of a teaching hospital. Reasons of inappropriate admissions and delayed discharges were classified and analyzed. Results of the valuation of some patients were subject to control by a committee of fully specialized hospital physicians. 63 (24%) of 260 admissions and 1005 (54%) of 1869 evaluated days of stay failed the AEP criteria. These patients could be well served by lower treatment intensity in outpatient clinics, nursery homes or their own homes. Such a shift in pattern of provided care requires profound organizational changes many of which are out of reach of individual acute hospitals. Despite some limitations we find AEP a useful tool for internal utilization review. External application of AEP in a representative sample of acute care hospitals could provide important data for future development of the Czech health care system.
Hospitalization↗
Commentary: issues and perspectives affecting CRNA practice. Regulation of health professionals, Part 1: Telepractice.
Although the requirement to protect the public welfare and safety is a right guaranteed to the states by the US Constitution's 10th amendment, which grants states the "police powers" of government, it is not an absolute power. The Commerce clause of the Constitution limits the power of states in creating barriers to intrastate commerce. Changes in the health care delivery system of the US, such as the use of corporate models such as managed care entities and health maintenance organizations, as well as health insurers' development of utilization reviews before approval of reimbursable procedures in individual cases, has prompted concerns with regard to the care of patients occurring outside the state in which the patient resides, by health care professionals not licensed in that state. Many states have considered such decision making an "unauthorized practice of medicine, or other practice" creating the necessity for some providers to obtain an many as 20 licenses to cover their practice. The practice of telemedicine (or telenursing or telehealth) falls into this quagmire, and thus efforts are ongoing to try to find ways to permit such practices while maintaining quality control, with or without additional state licenses.
Humans↗
[Digital film viewer versus conventional view boxes in the identification of bone and joint disorders].
PURPOSE: To compare the diagnostic accuracy of a digital film viewer (Smartlight 2000 Plus) versus a conventional view box for the identification of bone and joint disorders. MATERIAL AND METHODS: In order to evaluate the qualitative and quantitative differences of digital and conventional film viewers, 100 plain films of patients with bone and joint disorders taken in an emergency room January through May 1998 were reviewed utilizing both types of view boxes. Three radiologists expert of bone and joint disorders, independently compared the films, filled a form about the qualitative and quantitative analysis of the lesions depicted for each patient, and reported a few notes on the technical quality of the plain films in terms of exposure. The results were compared using the chi-square test (p < 0.005). RESULTS: Data analysis showed that the digital film viewer permitted a quicker reading of the film while decreasing the perception threshold for elementary lesions and ocular fatigue. All the radiographs read with the digital film viewer were considered technically adequate: the film quality was considered good in 10 cases and sufficient in 2. Two of the same radiographs read with the conventional view box were considered of good quality, nine were considered sufficient and one was considered insufficient due to overexposure. There were six cases of agreement and six of disagreement for the diagnosis: four were due to overexposure of the radiograph and two to better conspicuity provided by the digital film viewer. DISCUSSION: Correct image illumination is the first element a radiologist evaluates when reading a radiograph. A conventional view box may, when it is not properly maintained or when the radiograph is overexposed, decrease the radiologist's visual capacity. This increases the time required to read the radiograph and, therefore, physical and ocular fatigue, which in turn increases the risk of missing or misevaluating a lesion. A digital film viewer emits light with a variable intensity which is proportional to the optical density of the film. This increases the visual capacity of the radiologist and the lesion contrast, while reducing the factors which affect the radiograph reading. CONCLUSIONS: The use of a digital film viewer increased the visual capacity of the radiologist and eliminated the negative elements which complicated the radiograph reading and permitted the use of radiographs that would otherwise have been considered of poor quality due to overexposure. This, combined with the experience of the radiologist, decreased of the risk of missing or misevaluating a lesion.
Bone Diseases↗
Neuromuscular rehabilitation and electrodiagnosis. 2. Localized peripheral neuropathy.
This self-directed learning module highlights advances in diagnosis and treatment of focal injuries to peripheral and cranial nerves. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Nerve conduction and electromyographic techniques are employed as extensions of the physician's senses in clinical examination and diagnosis. The findings are used to plan treatment, and to predict and measure outcomes. Electrodiagnosis and medical and surgical treatments of nerve injuries are discussed in light of the managed-care utilization review of services.
Cranial Nerve Injuries↗