Controlling Costs and Changing Patient Care? : The Role of Utilization Management

Utilization management (UM) has become a strong trend in health care cost containment.

Under UM, some decisions are not strictly made by the doctor and patient alone.

Instead, they are now checked by a reviewer reporting to an employer or other paying party who asks whether or not the proposed type or location of care is medically necessary or appropriate. This book presents current findings about how UM is faring in practice and how it compares with other cost containment approaches, with recommendations for improving UM program administration and clinical protocols and for conducting further research. Table of ContentsFront MatterExecutive SummaryUtilization Management: Introduction and DefinitionsOrigins of Utilization ManagementThe Utilization Management Industry: Structure and ProcessImpact of Prior Review ProgramsHigh-Cost Case ManagementConclusions and RecommendationsAcknowledgmentsAppendixesAppendix A - Legal Implications of Utilization ReviewAppendix B - Utilization Management and Quality Assurance in HealthMaintenence Organiztions: An Operational AssesmentAppendix C - Utilization Management in Peer Review OrganizationsAppendix D - Summary of Public HearingsAppendix E - Summaries of Committee Site Visits to UtilizationManagement OrganizationsAppendix F - Analysis of Agreements Between Utilization ManagementOrganizations and Their ClientsAppendix G - Glossary and AcronymsAppendix H - Biographies of Committee MembersIndex