Controlling Costs and Changing Patient Care? -- Copyright -- Contents -- Preface -- Executive Summary -- CURRENT STATUS OF UTILIZATION MANAGEMENT -- HOW UTILIZATION MANAGEMENT IS EVOLVING -- ISSUES FOR THE FUTURE -- RECOMMENDATIONS FOR THE NEAR TERM -- Responsibilities of Employers and Purchasers -- Responsibilities of Utilization Management Organizations -- Responsibilities of Practitioners and Institutions -- Responsibilities of Patients -- LONGER-TERM RECOMMENDATIONS AND QUESTIONS -- Research On Effectiveness -- Practice Guidelines and Review Criteria -- Oversight of Utilization Management -- 1 Utilization Management: Introduction and Definitions -- WHAT IS UTILIZATION MANAGEMENT? -- Prior Review -- High-Cost Case Management -- Retrospective Utilization Review -- Other Cost-Containment Methods -- TWO NOTES OF CAUTION -- Obstacles To Evaluation -- Intrinsic Conceptual and Methodological Problems -- Common Behavioral Biases Against Evaluation -- Competition and Evaluation -- Forces Behind Rising Health Care Costs -- REFERENCES -- 2 Origins of Utilization Management -- THE GROWTH OF THIRD-PARTY FINANCING OF HEALTH CARE -- EARLY COST-MANAGEMENT EFFORTS BY THIRD PARTIES -- Management of the Risk Pool -- Design of the Benefit Plan -- Controls On Payments To Providers -- Constraints On Supply -- Utilization Review -- GOVERNMENT AND EMPLOYER INVOLVEMENT -- Federal Government Initiatives -- Private Purchasers Become an Force -- OTHER FACTORS GIVING RISE TO UTILIZATION MANAGEMENT -- Inappropriate Utilization as an Cost-Containment Target -- Variations in Utilization -- Inappropriate Utilization -- Linking Cost and Quality -- Improving the Tools and Structures for Utilization Management -- Information Resources -- Assessment and Education Strategies -- New Organizations -- CONCLUSION -- REFERENCES.

3 The Utilization Management Industry: Structure and Process -- INDUSTRY OVERVIEW -- THE REALITIES OF PRIOR REVIEW: HOW IS IT ACTUALLY DONE? -- How Prior Review Is Integrated with Other Administrative Functions -- How Basic Logistical Matters Are Handled -- Initiating Review -- Handling Telephone Calls -- Computerization -- How Nurse Reviewers Work -- What Role Do Physician Advisers Play? -- What Style Is Used with Attending Physicians? -- What Criteria Are Used to Assess Care? -- Lists of Procedures -- Exceptions Criteria -- Hospitalization Criteria -- Length-Of-Stay Norms -- Necessity of a Procedure -- How Criteria Are Adopted and Modified -- How Organizations Use Criteria -- Appeals Processes -- Reporting and Feedback Mechanisms -- SECOND-OPINION REQUIREMENTS -- LEGAL ISSUES -- CONCLUSION -- REFERENCES -- 4 Impact of Prior Review Programs -- DIRECTION OF AVAILABLE EVIDENCE: IMPACT ON UTILIZATION AND COST -- Before-and-After Studies -- Comparative Studies -- Multivariate Studies -- Impact of Second-Opinion Programs -- WEAKNESSES IN THE EVIDENCE ON EFFECTS OF PRIOR REVIEW -- EFFECTS OF PRIOR REVIEW ON SPECIFIC PARTIES -- Effects on Enrollees and Patients -- Quality of Care -- Navigating Health Care and Health Benefits -- Patient Costs, Comfort, and Convenience -- Effects on Health Care Practitioners and Institutions -- Physician-Patient Relationship -- Physician-Hospital Relations -- Provider-Purchaser Relations -- Effects of Prior Review on Purchasers -- CONCLUSION -- APPENDIX SOME METHODOLOGICAL ISSUES IN ASSESSING THE EFFECTS OF UTILIZATION MANAGEMENT PROGRAMS -- Claims Data -- Group Data -- Program Data -- Savings Calculations -- Other Interventions -- Medical Care Prices -- Noneconomic effects -- REFERENCES -- 5 High-Cost Case Management -- FOCUS OF HIGH-COST CASE MANAGEMENT -- ROLE OF THE PURCHASER -- HOW HIGH-COST CASE MANAGEMENT WORKS.

Operational Variations -- How Cases Are Identified and Screened -- Who Serves as Case Manager? -- How Case Managers Relate to Patients and Providers -- How Much Case Management Costs -- IMPACT OF HIGH-COST CASE MANAGEMENT -- EFFECTS OF HIGH-COST CASE MANAGEMENT ON SPECIFIC PARTIES -- Effects on Enrollees -- Effects on Health Care Providers -- Effects on Purchasers -- QUESTIONS ABOUT AVAILABLE EVIDENCE -- LEARNING CURVE IN HIGH-COST CASE MANAGEMENT -- POTENTIAL LEGAL ISSUES -- CONCLUSION -- REFERENCES -- 6 Conclusions and Recommendations -- CURRENT STATUS OF UTILIZATION MANAGEMENT -- HOW UTILIZATION MANAGEMENT IS EVOLVING -- Scope of Review -- Operational Efficiency -- Rationing -- ISSUES FOR THE FUTURE -- RECOMMENDATIONS FOR THE NEAR TERM -- Responsibilities of Employers and Purchasers -- Responsibilities of Utilization Management Organizations -- Responsibilities of Health Care Practitioners and Institutions -- Responsibilities of Patients -- RECOMMENDATIONS AND QUESTIONS FOR THE LONGER TERM -- Research on Effectiveness -- Practice Guidelines and Review Criteria -- Oversight of Utilization Management -- CONCLUSION -- Acknowledgments -- Appendixes -- Appendix A Legal Implications of Utilization Review -- Introduction -- The Types of Utilization Review -- The Sarchett Decision -- The Wickline Decision -- The Elusive Concept of Medical Necessity -- Liability of the Review Organization -- Negligence -- Existence of an Duty of Care -- The Standard of Care -- Causation -- Breach of Contract -- Insurance Bad Faith -- Infliction of Emotional Distress -- Warranty Theories -- Products Liability -- Defamation and Interference with Contractual Advantage -- Antitrust -- Liability of Consultants and Employees -- State Regulation -- Erisa Preemption -- Liability of the Employer or Payer -- Direct Liability -- Vicarious Liability -- Indemnity.

Liability of the Treating Physician -- Legal Issues For the Patient -- The Need For Expedited Review -- Payment For Unnecessary Medical Services -- Conclusion -- References -- Appendix B Utilization Management and Quality Assurance in Health Maintenance Organizations: an Operational Assessment -- Methodology -- Hmo Organizational Structure -- Market, Structural, and Operational Factors Affecting Hmo Performance -- The Health Care Marketplace -- Hmo Structure -- Hmo Operations -- Approaches to Utilization Management and Quality Assurance -- Underwriting Benefits -- Delivery of Health Services -- Quality Assurance -- Operational Problems Impairing Utilization Management and Quality Assurance Programs -- Utilization Management Programs -- Quality Assurance -- Design and Use of Physician Incentives -- Background -- Current Surveys Concerning Physician Incentives -- Administering Physician Incentives -- Policy and Research Issues -- Case Studies Introduction -- Case Study 1: Hospital-Sponsored Ipa -- Background -- Control Type -- Financial Incentives -- Design of Mis System -- Utilization Management -- Medical Director and Utilization Management Support Staff -- Case Study 2: Group-Model Hmo -- Background -- Control Type -- Financial Incentives -- Design of Mis System -- Utilization Management -- Medical Director and Utilization Management Support Staff -- Case Study 3: Carrier-Sponsored Hmo -- Background -- Control Type -- Financial Incentives -- Design of Mis System -- Utilization Management -- Medical Director and Utilization Management Support Staff -- Case Study 4: Carrier-Sponsored Hmo -- Background -- Control Type -- Financial Incentives -- Design of Mis System -- Utilization Management and Support Staff -- Medical Director and Utilization Management Support Staff -- Case Study 5: Physician-Sponsored Ipa -- Background -- Control Type.

Financial Incentives -- Design of Mis System -- Utilization Management -- Ipa Management -- Notes and References -- Appendix C Utilization Management in Peer Review Organizations -- References -- Appendix D Summary of Public Hearings -- Appendix E Summaries of Committee Site Visits To Utilization Management Organizations -- Organization 1 -- Organization 2 -- Organization 3 -- Organization 4 -- Organization 5 -- Organization 6 -- Organization 7 -- Organization 8 -- Organization 9 -- Organization 10 -- Organization 11 -- Organization 12 -- Appendix F Analysis of Agreements Between Utilization Management Organizations and Their Clients -- Contractual Descriptions of Prior Review Services -- Sources of Clinical Criteria and Standards -- Distinction Between the Review Determination and Purchaser's Decision To Pay For Services -- Indemnification and Liability Insurance Coverage -- Staffing and Performance Criteria -- Proprietary Information and Competition -- Appendix G Glossary and Acronyms -- Glossary -- Acronyms -- Appendix H Biographies of Committee Members -- Index.