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Use of utilization management methods in State Medicaid programs.

J A Buck1, H A Silverman

  • 1Substance Abuse and Mental Health Services Administration, USA.

Health Care Financing Review
|February 1, 1997
PubMed
Summary
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State Medicaid programs utilize various utilization management (UM) methods, with no adverse effects on care quality reported. Physician certification, however, was deemed minimally effective by over a third of states.

Area of Science:

  • Health Services Research
  • Public Health Policy
  • Healthcare Management

Background:

  • State Medicaid programs increasingly adopt utilization management (UM) strategies.
  • Understanding the scope and impact of these UM methods is crucial for healthcare policy.
  • Variability exists in the adoption of optional UM methods across states.

Purpose of the Study:

  • To document the utilization of optional and mandated UM methods by State Medicaid programs.
  • To assess state perceptions of the impact of UM methods on access and quality of care.
  • To evaluate the effectiveness of specific mandated UM methods, such as physician certification.

Main Methods:

  • Survey of State Medicaid programs regarding their use of various UM methods.
  • Analysis of the range and median number of UM methods employed per state.

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  • Categorization of UM methods into optional and mandated.
  • Collection of state-reported data on perceived effects on care access and quality.

    • Main Results:

    • The number of optional UM methods used by states ranged from zero to eight, with a median of five.
    • A majority of states utilize programs for ambulatory surgery, preadmission certification, lock-in, primary-care case management, and targeted case management.
    • No UM method was perceived by states to adversely affect access or quality of care.
    • Over one-third of states rated physician certification, a mandated UM method, as minimally effective.

    Conclusions:

    • State Medicaid programs employ a diverse set of UM methods.
    • Current UM strategies are not perceived to negatively impact care access or quality.
    • Mandated UM methods, like physician certification, may require further evaluation for effectiveness.