Question

As utilization review techniques are implemented by MCOs, how has this had an impact on patients being able to access the care they need? What are the positives and negatives of limiting access to some providers? What are the potential financial implications to both the patient and the provider for choosing to comply or not to comply with these requirements? References included if any

Answer 1

The increase in health care costs has put the concept of "cost control" of the highest importance. The reimbursement plans were rewarding physicians for providing more expensive and sometimes

unnecessary treatment in the earlier times. Then the alternative market-driven plans were developed and which was giving a penalty for physicians if providing unnecessary care. Then third-party payers formulated and depended on managed care products to improve the relationship among third-party payers, physicians, and patients. In MCOs the risk of financial loss shifted from third-party

payers to physicians.

The use of diagnostic and therapeutic services has increased with the advanced technology and the care delivery has shifted to outpatient settings, yet the healthcare costs have not slowed. This shift to the delivery of medical care outside the hospital setting demands an effective utilization review (UR) in both inpatient and outpatient settings. UR can be done through private organizations internal programs and through external review programs of insurance carriers. Utilization review has been driven by increased medical costs and by the redesign of insurance benefit plans. They aimed at inclusion of financial incentives and penalties and copayments.

The two basic forms of managed care organizations are health maintenance organizations (HMOs) and preferred provider organizations (PPOs).

Advantages and Disadvantages:

Utilization review has attempted to control the use of MCOs through preadmission certification and concurrent review, second surgical opinions from experts, and medical case management. This process helps in the identification of patients, before or during hospitalization who could safely receive treatment outside the hospital.

The in-patient mental health and substance-abuse programs must use the intensive review because of potential high expenditures for such services. Indicators of practice are developed and can be utilized to determine treatment plans. The care management in all MCOs will increase with the improvement in utilization review techniques.

Managed care products can be dangerous to individual patients and to the society.Only the designer - third-party payers-can minimize the ill effects. The benefit to the society will be limited if the utilization review technique cost injury to the patient.

References:

1.http://racism.org/index.php?option=com_content&view=article&id=1419:managedcare&catid=99&Itemid=267

2. Howard L. Bailit and Cary Sennett, Utilization management as a cost-containment strategy, Health Care Financ Rev. 1992 Mar; 1991(Suppl): 87–93.