New methods for evaluating utilization management programs.
Blue Cross and Blue Shield of Massachusetts, Inc (BCBS), has developed two new methods for measuring the effect of utilization management (UM) in reducing unnecessary hospital use. The "program component" method measures the separate effect of preadmission review, concurrent review, and discharge planning. The "savable days" method produces a composite measure of the effectiveness of the program as a whole. The use of these two methods is illustrated with five years of utilization review data from the BCBS nongroup insurance product. The results can be used by operations managers and policymakers to measure the performance of individual UM components and the program as a whole, to establish goals and monitor program performance, to modify the program in response to changing utilization patterns, to assist in developing premiums, to establish risk-sharing agreements with employers or providers, and to demonstrate the effectiveness of the program for use in marketing.
Payne
S M
SM
Health Services Department, Boston University School of Public Health, MA 02118-2394.
Campbell
D
D
Penzias
B G
BG
Socholitzky
E
E
D054598:Blue Cross Blue Shield Insurance Plans / Q000706:statistics & numerical data; D003211:Concurrent Review / Q000592:standards; D007345:Insurance Claim Review / Q000592:standards*; D007354:Insurance, Major Medical / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D008329:Managed Care Programs / Q000592:standards / Q000706:statistics & numerical data; D008404:Massachusetts; D010343:Patient Admission / Q000706:statistics & numerical data; D010347:Patient Care Planning / Q000592:standards; D010351:Patient Discharge / Q000592:standards; D015397:Program Evaluation / Q000379:methods*; D014481:United States; D014600:Utilization Review / Q000592:standards*