The need for ambulatory medical necessity review in multispecialty groups

With the proliferation of HMOs, PPOs and other managed care payment methodologies which demand quality and efficiency, there is a shift from hospitals to clinics that creates the need for ambulatory care medical necessities review (utilization management). It is predicted that by the year 1995, 90 percent of all insured patients will be in a managed care system of some kind, thus the pressures to develop ambulatory care utilization review will likewise increase. Although there is some development in outcome measurement methodologies, currently there is an immediate need for UR techniques in the ambulatory care setting, techniques which are somewhat similar to traditional hospital methodologies. However, instead of the focus being case-by-case analyses, the large multispecialty group practice must rely on techniques which focus their review on large volumes of small services. Development of methodologies to influence and improve quality and efficiency is occurring in multiple areas. These methodologies are making inroads into the ambulatory setting and going far beyond traditional hospital UR. As Christian Ramsey Jr., M.D., notes, three methodologies are: 1. outcomes measurement; 2. data/information; and 3. continuous quality improvement (CQI) techniques. Indeed, the winds of demand for medical services are blowing in the direction of ambulatory care settings. Multispecialty group practices, like the sails of a ship, will catch this wind. To steer a course in the direction of improved quality and efficiency, the medical group practice must implement methodologies in ambulatory medical necessity review.(ABSTRACT TRUNCATED AT 250 WORDS)