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Related Experiment Videos

New methods for evaluating utilization management programs.

S M Payne1, D Campbell, B G Penzias

  • 1Health Services Department, Boston University School of Public Health, MA 02118-2394.

QRB. Quality Review Bulletin
|October 1, 1992
PubMed
Summary
This summary is machine-generated.

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Blue Cross and Blue Shield of Massachusetts developed new methods to measure utilization management (UM) effectiveness in reducing hospital use. These tools help assess individual UM components and overall program performance for healthcare operations and policy.

Area of Science:

  • Health Services Research
  • Healthcare Management
  • Health Economics

Background:

  • Healthcare systems face challenges with unnecessary hospital utilization.
  • Effective utilization management (UM) is crucial for controlling costs and improving patient outcomes.
  • Quantifying the impact of UM programs is essential for performance evaluation and strategic decision-making.

Purpose of the Study:

  • To introduce and illustrate two novel methods for measuring the impact of utilization management (UM) on reducing unnecessary hospital use.
  • To provide tools for healthcare operations managers and policymakers to assess UM program effectiveness.
  • To demonstrate the application of these methods using real-world utilization review data.

Main Methods:

  • Development of the "program component" method to evaluate individual UM strategies like preadmission review, concurrent review, and discharge planning.

Related Experiment Videos

  • Introduction of the "savable days" method for a comprehensive assessment of the overall UM program's effectiveness.
  • Application and illustration of both methods using five years of utilization review data from a nongroup insurance product.

    • Main Results:

    • The "program component" method allows for granular analysis of specific UM interventions.
    • The "savable days" method provides a holistic measure of the UM program's success in reducing hospital days.
    • The data analysis demonstrates the practical utility of these methods in a real-world setting.

    Conclusions:

    • The developed methods offer valuable insights into the performance of individual UM components and the program overall.
    • These tools support data-driven decision-making for optimizing UM strategies, setting performance goals, and managing healthcare costs.
    • The findings highlight the importance of robust measurement for demonstrating UM program value in marketing and policy contexts.