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Controlling Costs and Changing Patient Care? : the Role of Utilization Management.
| Clasificación: | Libro Electrónico |
|---|---|
| Autor principal: | |
| Formato: | Electrónico eBook |
| Idioma: | Inglés |
| Publicado: |
Washington :
National Academies Press,
1988.
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| Temas: | |
| Acceso en línea: | Texto completo |
Tabla de Contenidos:
- 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 DefinitionsWHAT 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 PlanControls 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 ProcessINDUSTRY 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 ModifiedHow 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.