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PubMed1998

Effects of utilization management on patterns of hospital care among privately insured adult patients.

OBJECTIVES: This study examined the effects of utilization management review activities on patterns of hospital care among a sample of adult patients insured through a managed fee-for-service plan. METHODS: The study was a retrospective analysis of insurance administrative data representing a case series of patients for whom utilization management review was performed. Two review activities were analyzed: pre-admission review and concurrent (continued stay) review. Patients were 49,654 privately insured adult patients reviewed for care between January 1989 and December 1993. Review outcomes included inpatient or outpatient care denied, site of treatment shifted (from inpatient to outpatient), or reduction in requested hospital days (total days requested - total days approved). RESULTS: Few patients (<1%) were denied care at time of admission or were required to obtain outpatient instead of inpatient care. More common was action taken to limit length of stay by concurrent review, which accounted for 83% of the total reduction (25,197 requested days) in inpatient care. Utilization management became more restrictive with time: the number of days approved declined by 15% to 50% from 1990 to 1993, depending on the type of admission. Utilization management was most forceful in restricting care for mental health patients, who represented 5.7% of the study population but accounted for 54.7% of the total reduction in requested days. CONCLUSIONS: The utilization management program appeared to limit hospital care by managing length of stay once patients were admitted. The effects of restricting length of stay in this manner on quality and health outcomes should be investigated.

Adult↗
PubMed1996

Developing a cooperative provider-based statewide peer review service: early experience.

The purpose of this study was to demonstrate the feasibility of a model of overcoming local barriers to physician peer review through development of a statewide provider-based physician peer review service. For this purpose, the cooperative demonstration project of the Institute for Quality Healthcare, The University of Iowa and The Robert Wood Johnson Foundation, was used. A consortium of 43 Iowa hospitals developed a physician peer review service utilizing a pool of physician reviewers from member hospitals. Thirty-six peer reviews were conducted in 23 different hospitals by 37 different reviewers throughout the state of Iowa in the first 2 years of operation. Reviews of surgical specialists, psychiatrists, and psychiatric services were requested most frequently. The satisfaction of hospitals with the physician peer review service has thus far been gratifying. The long-term financial viability of the physician peer review service has yet to be demonstrated. This cooperative organizational model of a provider-based physician peer review service may be reproducible and valuable to health care providers in other parts of the United States.

Academies and Institutes↗
PubMed1987

Medicare and Medicaid programs; entities performing quality of care review of services provided by risk-basis health maintenance organizations and competitive medical plans--HCFA. Final rule with comment period.

This final rule provides for review by Utilization and Quality Control Peer Review Organizations (PROs) of the quality of care furnished by risk-basis health maintenance organizations and competitive medical plans under 42 CFR Part 417, Subpart C. It also provides for this same review by non-PRO entities and identifies the requirements that these non-PRO entities must meet. This rule is necessary for the timely implementation of section 1154(a)(4) of the Social Security Act, as amended by section 9353(a)(2) of the Omnibus Budget Reconciliation Act of 1986 (Pub. L. 99-509).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1993

Payment mechanisms, nonprice incentives, and organizational innovation in health care.

Health care organizational structures support alternative combinations of payment and nonprice incentives for physicians, hospitals, and other providers. Changing perceptions among purchasers of the relative effectiveness of particular mechanisms lead to changes in the market shares held by particular organizational structures. This paper uses principal-agent and transactions cost economics to develop a conceptual matrix for understanding organizational innovation in the health care system. It contrasts the differing incentives in retrospective versus prospective payment mechanisms, arms-length review versus peer review mechanisms for controlling inappropriate utilization, and "free choice of physician" versus selective contracting mechanisms for structuring the basic insurer-provider relationship.

Delivery of Health Care↗
PubMed1984

Medicare and Medicaid programs; utilization and quality control peer review organization (PRO); assumption of responsibilities and Medicare review functions and coordination of Medicaid with peer review organization--HCFA. Proposed rule.

This proposal would implement portions of the Peer Review Improvement Act of 1982 (Title I, Subtitle C of the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), Pub. L. 97-248) and the Social Security Act Amendments of 1983 (Pub. L 98-21) by establishing the review functions to be performed by a Utilization and Quality Control Peer Review Organization (PRO). The 1983 amendments to the Social Security Act amended TEFRA by requiring that effective October 1, 1983, hospitals receiving payment under the Medicare prospective payment system (PPS) are required to maintain an agreement with a PRO if there is one for the area. Effective October 1, 1984, hospitals are required to have an agreement with a PRO in order to receive Medicare payments. These proposed regulations outline the relationships among PROs, Medicare fiscal intermediaries and carriers, providers, practitioners, and beneficiaries upon the PRO's assumption of conduct of review for those hospitals under PPS and for all other facilities. The proposal would also describe the relationship between PROs and State Medicaid agencies that contract with PROs to perform review.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1985

Medicare and Medicaid programs; utilization and quality control peer review organization (PRO): assumption of Medicare review functions and coordination with Medicaid--HCFA. Final rule.

This rule describes the review functions to be performed by a utilization and quality control peer review organization (PRO). It outlines the relationships that will be established among PROs, Medicare fiscal intermidiaries and carriers, providers, practitioners, and beneficiaries when a PRO assumes its review responsibilities. It also describes the relationship that should exist between PROs and State Medicaid agencies that contract with PROs to perform review. This rule implements portions of the following statutes: Peer Review Improvement Act of 1982 (Title I, Subtitle C of the Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248), Social Security Amendments of 1983 (Pub. L. 98-21), Deficit Reduction Act of 1984 (Pub. L. 98-369).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1991

Medicare program; Peer Review Organizations: revised scopes of work for Delaware, Missouri, Montana, Nebraska, New Jersey, Nevada, Oklahoma, Rhode Island, South Carolina, Washington, and Wyoming--HCFA. Final notice.

This notice describes requirements for the review activities of Utilization and Quality Control Peer Review Organizations (PROs) for the next contract cycle in the States listed above. Section 1153(h)(1) of the Social Security Act requires us to publish any new policy or procedure adopted by the Secretary that affects substantially the performance of PRO contract obligations at least 30 days before the date the policy or procedure is to be used. Specifically, this notice describes significant changes in the way in which cases will be selected for review and also describes continuing requirements. This notice also implements provisions of the Omnibus Budget Reconciliation Act of 1990 and announces the future direction of the PRO program.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1986

Hospital utilization by health maintenance organizations. Separating apples from oranges.

The hospitalization rate of HMOs is reported to be 444 bed days per 1,000 enrollees per year. It is often forgotten that there is also out-of-plan utilization. A review of previous studies and a survey of reporting practices by three HMOs illustrate many problems with HMO utilization data. HMO rates, like those of other insurers, reflect only the hospital admissions that the plans know about and pay for, not the total hospital experience of their enrollees. While only a thorough tracking of subscriber utilization of all insurers and institutions will provide estimates of the magnitude of unreported admissions and their impact on utilization rates, this report enumerates the ways in which patients may receive inpatient care without the HMO having a record of the admissions and/or having to pay for them. It was found that admissions can be unreported when another insurer or institution pays (e.g., Medicare, No Fault, Workmen's Compensation, duplicate coverage, school health and liability insurance or VA, military, municipal, and state hospitals); when the HMO does not cover benefits (e.g., cosmetic and oral surgery, experimental procedures, long-term psychiatric, chronic, or rehabilitation stays); and when HMO coverage is denied for procedural reasons (e.g., catastrophic stays covered by reinsurance, newborns, voluntary "leakage," or improper following of HMO procedures). True HMO rates are unknown but are estimated by some authors to be 7-37% higher than the reported figure, depending on which types of unreported use are estimated. There is a need for future analyses to quantify true hospitalization rates of enrollees of HMOs and other insurers.

Adolescent↗
PubMed2004

Estimation of an optimal radiotherapy utilization rate for gastrointestinal carcinoma: a review of the evidence.

BACKGROUND: Radiotherapy utilization rates for cancer vary widely, both within and between countries. The optimal proportion of patients with gastrointestinal malignancies who should receive at least one course of radiotherapy at some time during their illness is an important benchmark. METHODS: The authors studied treatment guidelines and treatment reviews to identify the indications for radiotherapy for patients with gastrointestinal malignancies. Optimal radiotherapy utilization trees were constructed to show the clinical attributes of patients with gastrointestinal carcinomas who will benefit from radiotherapy. Epidemiologic incidence data for each of these clinical attributes were obtained to calculate the optimal proportion of all patients with gastrointestinal malignancies for whom radiotherapy was considered appropriate. Optimal rates of radiotherapy use were compared with actual rates in population-based studies to assess any discrepancies between actual and optimal radiotherapy utilization rates. RESULTS: Radiotherapy was indicated in 80% of patients with esophageal carcinoma, 68% of patients with gastric carcinoma, 57% of patients with pancreatic carcinoma, 13% of patients with carcinoma of the gallbladder, 0% of patients with hepatic carcinoma, 14% of patients with colon carcinoma, and 61% of patients with rectal carcinoma. The actual radiotherapy utilization rates for most of these gastrointestinal malignancies fell well short of optimal rates, which were derived from evidence-based treatment guidelines. CONCLUSIONS: It is possible to model optimal radiotherapy utilization using published treatment guidelines and existing incidence data. There was a discrepancy between the optimal and actual rates of radiotherapy utilization for patients with carcinomas of the esophagus, stomach, pancreas, and rectum. Strategies to implement evidence-based clinical guidelines are recommended.

Benchmarking↗
PubMed2001

Effect of sumatriptan on health care resource use among patients with migraine.

Previous investigations examining health care resource utilization in patient populations have shown patients with migraine to consume significantly higher health care resources compared with individuals without migraine. The purpose of this study was to compare health care resource and narcotic use in migraineurs prescribed sumatriptan (oral, subcutaneous, or nasal) with those not prescribed sumatriptan.

Adult↗
PubMed1975

What kind of criteria?

The modern concept of medical audit mandates comparison of care against preset explicit criteria. The format in which those criteria are framed plays a crucial role in determining the types of deficiences liable to be uncovered. Formats describing care as "consistent with" acceptable practice do not reveal meaningful information, and the Joint Commission on Accreditation of Hospitals' emphasis on "outcome" to the exclusion of "process" is also unacceptable. A detailed format for disease-specific criteria is described; it may not be feasible for widespread use.

Hernia, Inguinal↗