S D Stratton | PubMed Health

PubMed2001

Informatics in managed care: HIM adds value to data.

The third installment of the Journal of AHIMA's special series on managed care focuses on informatics--methods that add value to data, turning it into useful information. How do informatics and managed care fit together and what is HIM's role in this picture? The HIM professional's knowledge is critical to the health team responsible for the interpretation and use of statically valid information. For example, HIM professionals are well positioned in their understanding of the construct and application of coding classification systems (ICD-9-CM, CPT, etc.), and groupers (DRGs, APCs, ETGs, etc.). Their unique training positions them to understand the associated rules, principles, guidelines, and nuances associated with correct coding and grouping. And when codes or groupers change, HIM professionals work closely with the health team to ensure parity, validity and reliability of the appropriate data or data sets. Managed care organizations use value-added data, as you will see in this article, to evaluate contract pricing, develop contracts, evaluate existing services or detail benefit plans, process and in some instances pay claims, and report results to a number of interested parties. The previous article in this series ("Can You Manage Managed Care?" July/August 2001) focused on effective management of data, including data acquisition. This article takes us to the next level, where informatics creates value-added information, and discusses some important uses of this information within managed care. These articles build on two of the functional areas that form the HIM process within managed care organizations. Author Scott Stratton studied under the creators of DRGs and was involved in the development of their nursing home counterpart, RUGs. He also has worked with the creators of ETGs. As a result, he can present the perspective and context within which these systems were created and intended. and how they form the foundation for informatics as a functional area within managed care.

Diagnosis-Related Groups↗

PubMed1995

Effect of utilization review in a fee-for-service health insurance plan.

BACKGROUND: Although utilization review is widely used to control health care costs, its effect on patterns of health care is uncertain. METHODS: In 1989, New York City and its unions temporarily replaced actual utilization review with sham review for half the participants in the city's fee-for-service health insurance plan. We compared the health services provided to 3702 enrollees whose requests were subjected to utilization review (the review group) with the services provided to 3743 enrollees whose requests received sham review and were automatically approved for insurance coverage (the nonreview group). The enrollees, physicians, and hospitals were all unaware of the group assignments. RESULTS: During the study period (mean duration, eight months), the members of the review group underwent 1255 procedures in 20 categories of procedures for which second opinions were required (such as breast, cataract, foot, hernia, and hip-replacement surgery, as well as hysterectomy and coronary bypass surgery), and the members of the nonreview group underwent 1365 procedures (P = 0.02). The members of the review group had 124 fewer procedures in doctors' offices and hospital outpatient departments (P = 0.002). In the following year, the members of the review group underwent 248 procedures from the 20 categories, and the members of the nonreview group underwent 234 (P = 0.46). No other differences in patterns of care were found between the groups, including rates of hospital admission to medical-surgical, substances-abuse, or psychiatric units; average lengths of hospital stay; the percentage of enrollees who received preadmission testing; or rates of use of home care. During the study period, the mean age-adjusted insurance payments per person were $7,355 in the review group and $6,858 in the nonreview group (P = 0.06). CONCLUSIONS: The utilization-review program reduced the performance of diagnostic and surgical procedures for which second opinions were required and did not merely delay them until the following year. Otherwise, the program had little effect. Alternatively, actual review and sham review may both have decreased the use of hospital services, with patients or their physicians choosing more efficient treatment when they believed that care would be reviewed.

Case Management↗