Utilization managers in Medicare risk contract HMOs: from control to collaboration

A study of utilization management (UM) practices in 13 health maintenance organizations (HMOs) with Medicare members was undertaken as part of an evaluation of the Medicare Risk Contract strategy. Although there were significant variations among HMOs, the common challenges of managing care for this particular population also led to important similarities. Most notable was the emphasis on redirecting the focus of control-oriented utilization review to promotion of continuous improvement in care management. The multiple medical and social service needs of Medicare beneficiaries have forced HMOs to cultivate close collaboration with physicians and UM personnel. Thus, UM personnel are involved throughout the continuum of care and play an important role in assisting HMOs to approach the "seam-less delivery system" ideal. HMOs report that the experience of managing care for Medicare members has made them more responsive to serving all of their members and to promoting long-term partnerships with their physicians.