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Utilization Review

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  • Topic: Utilization review
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Medical Directors Often Apply Different Definitions of "Medical Necessity"

August 1, 2003 | Program Result

In this 2000–2001 project, Linda Bergthold, PhD, and researchers at Stanford University, Stanford, Calif., surveyed health plan medical directors in 48 states about medical necessity decision making. The study provides input for policy-making at the state and national levels.

Physicians Among the Chief Drivers of High Drug Costs

January 1, 2001 | Program Result

During the 1980s, expenditures on pharmaceuticals nationwide increased by 152 percent. HMOs implemented a number of cost-control mechanisms to slow the rate of growth of pharmaceutical expenditures, and were successful in doing so compared to fee-for-service health plans.

Making Health Insurance More Affordable for Small Businesses

January 1, 2001 | Program Result

Starting in September 1991, researchers at the Pittsburgh Research Institute, Pittsburgh, compared the health care costs and use for employees at small firms and individual health plan subscribers with employees at large firms.

Access to Care Impacts Hospitalization Rates for Ambulatory Care Sensitive Conditions

April 1, 2001 | Program Result

The University of California studied access to primary care in selected communities to assess whether hospitalization rates for certain chronic conditions typically managed by outpatient care are valid and useful measures of community access to care.

Poor More Likely to be Hospitalized for Diseases Preventable with Primary Care

July 1, 2001 | Program Result

The United Hospital Fund of New York worked to develop, validate and implement a research technique called small-area analysis, used to identify communities with high rates of unnecessary hospitalization and limited access to primary care.

Variations Found During Physician Profiling Study Are Difficult to Explain

March 1, 2000 | Program Result

The Center for Research in Ambulatory Health Care Administration developed, tested and demonstrated a national physician profiling system for ambulatory health care.

How Managed Care Can Set Limits on Medical Technology - and Look Good

September 1, 2000 | Program Result

From 1996 to 1998, Harvard Pilgrim Health Care examined how insurers, employers and other purchasers of health care decide which medical technologies to provide to consumers under resource constraints.

How Managed Care Allocates Resources

March 1, 1998 | Program Result

The Hastings Center, a nonprofit bioethics research institute located in Garrison, N.Y., used applied research to examine the ethical questions involved with resource allocation by managed care organizations.

How Do Doctors Decide What Care is Necessary for Mental Health Problems?

November 1, 1996 | Program Result

Harvard Pilgrim Health Care documented the implicit criteria used to determine "medical necessity" related to mental health, and the influences of financial incentives and organizational arrangements on medical necessity decisions.

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