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Utilization managers in Medicare risk contract HMOs: from control to collaboration
1Department of Health Administration, Medical College of Virginia-Virginia Commonwealth University, Richmond 23298.
QRB. Quality Review Bulletin
|April 1, 1993
Summary
Health maintenance organizations (HMOs) managing Medicare members shifted utilization management (UM) from control to continuous care improvement. This collaboration enhanced care delivery for all members and physician partnerships.
Area of Science:
- Healthcare Management
- Health Services Research
- Public Health Policy
Background:
- Medicare Risk Contract strategy necessitates effective utilization management (UM) in Health Maintenance Organizations (HMOs).
- Medicare beneficiaries present complex medical and social needs requiring integrated care approaches.
Purpose of the Study:
- To examine UM practices within HMOs serving Medicare members.
- To identify common challenges and similarities in care management for this population.
- To assess the impact of Medicare member management on overall HMO responsiveness and physician relations.
Main Methods:
- A study involving 13 Health Maintenance Organizations (HMOs) with Medicare members.
- Analysis of utilization management (UM) practices and their evolution.
- Qualitative assessment of collaboration between UM personnel, physicians, and HMOs.
Main Results:
- Significant variations in UM practices existed among HMOs, yet common challenges fostered similarities.
- A notable shift occurred from control-oriented utilization review to promoting continuous improvement in care management.
- HMOs developed closer collaborations with physicians and UM personnel due to Medicare beneficiary needs.
- UM personnel became integral across the care continuum, aiding the pursuit of seamless care delivery.
Conclusions:
- Managing Medicare members prompted HMOs to enhance responsiveness to all enrollees.
- Experience with Medicare members fostered stronger, long-term partnerships between HMOs and physicians.
- UM practices evolved towards a more collaborative, continuous improvement model in integrated healthcare systems.
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