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Special Report: Annotated Bibliography for
Managed Behavioral Health Care 1989-1999
Utilization
Management
387. Baker, F., & Vischi, T. (1989). Continuity of care and the control of
costs: Can case management assure both? Journal of Public Health Policy,
10, 204-213.
Traditionally, case-managed services have focused on individual needs through providing com-prehensive,
flexible, and continuous services to mentally ill persons. The more recent emphasis
on managed care belies an increasing concern with cost control. This article explores the
potential conflict between the goals of continuity of care and of cost control, and describes a
number of steps to reduce the potentially negative effects of these competing policies.
Keywords: utilization management
388. Belcher, J. R. (1993). The trade-offs of developing a case management
model for chronically mentally ill people. Health and Social Work, 18,
20-31.
This article describes the role of case management in caring for chronic mentally ill people.
While case management appears to be an ideal method to improve the quality of care and con-trol
mental health costs, the author cautions about the difficulty of accomplishing both goals
simultaneously. The article reviews different case management and brokering models and
argues that social work professionals need to play a key role in proposing and implementing
case management models that match client needs with appropriate services and that accurately
reflect the costs of providing these services.
Keywords: case management, models, serious mental illness, utilization management
389. Clark, R. E., & Fox, T. S. (1993). A framework for evaluating the
economic impact of case management. Hospital and Community
Psychiatry, 44, 469-73.
Confusion about the efficacy and cost-effectiveness of alternative models of case management
for mental health care stems in part from poorly defined assumptions about outcomes and
unclear theories of the effect of case management on costs. This article identifies and discusses
some of the determinants of cost-effective case management such as characteristics of the case
management model, characteristics of clients served, and the administrative and financial con-text
in which a program is implemented. Several models of case management are described,
focusing on the ways in which these models differ with regard to resource management. A crit-ical
distinction between models with implications for both costs and outcome is the extent to
which each is client-directed or case-manager-directed. The authors conclude that case manage-ment
has the potential to reduce costs, and to improve the lives of people with mental illness, but that it is not likely to do so unless unambiguous goals are set and the mechanisms for
achieving them are clearly defined.
Keywords: case management, models, utilization management
390. Frank, R. G., & Brookmeyer, R. (1995). Managed mental health care
and patterns of inpatient utilization for treatment of affective disorders.
Social Psychiatry and Psychiatric Epidemiology, 30(5), 220-223.
This analysis estimates the impact of managed care on the provision of hospital care for
depression, using a database of individuals insured by large American corporations. The
authors assessed the effects of managed care on the cost per episode and the likelihood of re-hospitalization.
Results of the analysis suggest that the managed care strategies of utilization
review and case management have clear short-run impacts. Pre-admission certification pro-grams
also resulted in both long- and short-term savings through a reduction of both episode
duration and re-hospitalization.
Keywords: costs, depression, utilization management
391. Gabbard, G. O., Takahashi, T., Davidson, J., Bauman-Bork, M., &
Ensroth, K. (1991). A psychodynamic perspective on the clinical impact of
insurance review. American Journal of Psychiatry, 148, 318-323.
This article explores the impact of managed care and utilization review on clinicians, their
clients, and families. According to the authors, utilization review creates uncertainty about the
length of stay for psychiatric inpatient care, and chaotic treatment planning. The authors argue
that managed psychiatric care has led to adverse outcomes for many patients through prema-ture
discharge and a reluctance to hospitalize. Five case studies are presented to illustrate the
authors’ points about the negative impact of utilization review on inpatient psychiatric care.
The authors conclude with a call for better outcome studies on the cost-effectiveness of extend-ed
hospital treatment and for increased collaboration between payer and provider.
Keywords: utilization management
392. Glazer, W., & Morgenstern, H. (1993). The impact of utilization
management on hospital length of stay and illness outcome.
Administration and Policy in Mental Health, 21, 41-49.
This article presents an experimental model to determine the effect of utilization management
on the cost and outcome of inpatient psychiatric treatment. Two hypotheses would be tested:
that utilization management feedback results in a reduction in the average length of stay, and
that utilization management does not adversely affect illness outcome after hospitalization.
The design and methodological factors that must be considered to implement such a study are
also discussed.
Keywords: utilization management
393. Goldstein, J. M., Bassuk, E. L., Holland, S. K., & Zimmer, D. (1988).
Identifying catastrophic psychiatric cases: Targeting managed-care
strategies. Medical Care, 26, 790-799.
Many utilization review programs have developed standardized criteria (generally diagnosis-based)
to identify and monitor potentially catastrophic and high-cost cases. These criteria,
however, do not consider several factors that might predict catastrophic illness, such as age,
gender, and treatment setting and location. The study, based on claims data from more than
3,000 psychiatric inpatient admissions, demonstrates that these factors together and alone may
contribute to long stays and high costs. High costs and long stays were more likely to be asso-ciated
with adolescent admissions and admissions involving major affective, organic, and eat-ing
disorders. Catastrophic admissions were also more likely to occur in free-standing psychi-atric
hospitals. Long stays were more likely in the Northeast, and high-cost cases in the West.
These findings suggest that case managers take patient and setting characteristics—not just
diagnosis—into account when determining which cases should receive special attention.
Keywords: utilization management
394. Goldstein, L. S. (1990). Linking utilization management with quality
improvement. Psychiatric Clinics of North America, 13, 157-169.
This article compares and contrasts utilization management and quality improvement and
describes how utilization management can lead to quality improvement. The goal of utiliza-tion
management is efficiency. Preadmission authorization, admission review, case manage-ment,
and drug use evaluation are examples of utilization management. The goal of quality
improvement is to ensure that the structure and process of care is effective. Quality improve-ment
activities include the development of normative and empirical criteria, and outcome
studies. Despite their different goals, utilization management data, such as patterns of
resource utilization, can be used to ensure quality. The article describes a drug utilization
evaluation that identified potentially problematic prescribing practices at a psychiatric unit.
The findings catalyzed efforts to educate psychiatrists to ensure quality.
Keyword: quality assurance, utilization management
395. Gotowka, T. D., & Smith, R. B. (1991). Focused psychiatric review:
Impacts on expense and utilization. Benefits Quarterly, 7(4), 73-81.
This article reports the results of an evaluation to determine whether Focused Psychiatric
Review (FPR), Aetna’s utilization review program, reduces the use and costs of psychiatric
hospitalization. Hospital utilization was compared using claims data for approximately 16,000
beneficiaries who were subject to FPR, and 11,000 non-FPR controls. The study found that
FPR resulted in lower admission rates and lengths of stay, and that initiating case management
before admission led to shorter lengths of stay and lower hospital costs. The study also found
that length of stay is affected by day of admission, because Tuesday through Friday admissions
are often carried over an additional weekend. FPR has a greater impact on psychiatric disor-ders
than on substance abuse disorders and on nonpsychoses than on psychoses. These reduc-Annotated 393. Goldstein, J. M., Bassuk, E. L., Holland, S. K., & Zimmer, D. (1988).
Identifying catastrophic psychiatric cases: Targeting managed-care
strategies. Medical Care, 26, 790-799.
Many utilization review programs have developed standardized criteria (generally diagnosis-based)
to identify and monitor potentially catastrophic and high-cost cases. These criteria,
however, do not consider several factors that might predict catastrophic illness, such as age,
gender, and treatment setting and location. The study, based on claims data from more than
3,000 psychiatric inpatient admissions, demonstrates that these factors together and alone may
contribute to long stays and high costs. High costs and long stays were more likely to be asso-ciated
with adolescent admissions and admissions involving major affective, organic, and eat-ing
disorders. Catastrophic admissions were also more likely to occur in free-standing psychi-atric
hospitals. Long stays were more likely in the Northeast, and high-cost cases in the West.
These findings suggest that case managers take patient and setting characteristics—not just
diagnosis—into account when determining which cases should receive special attention.
Keywords: utilization management
396. Hennessy, K. D., & Green-Hennessy, S. (1997). An economic and
clinical rationale for changing utilization review practices for outpatient
psychotherapy. The Journal of Mental Health Administration, 24(3),
340-349.
Given the trend toward managed mental health organizations, there has been increased cost-consciousness
in the financing and delivery of mental health and substance abuse services.
In this paper, the authors examine how management strategies that result from these pressures
have affected mental health and substance abuse services. After reviewing the evolution and
application of managed care to behavioral health, they argue that pressures to reduce costs
have led to the over-application of utilization review (UR) in a way that may be economically
and clinically counterproductive. They provide several rationales for changing UR for outpa-tient
psychotherapy as well as some alternatives to micromanaging outpatient psychotherapy
benefits in an effort to promote a balance between economic and clinical goals.
Keywords: economics, psychotherapy, substance abuse, utilization management
397. Hersch, R. G. (1994). Mental health’s contribution to the financial
performance of a utilization management program. Managed Care
Quarterly, 2(2), 71-78.
This study uses data from a national utilization management program, covering approximate-ly
3.4 million individuals from 1989 through June 1993, to analyze the costs and benefits of
mental health utilization review compared with medical, surgical, and maternity management.
Analysis revealed that while the costs of performing mental health utilization management
are significantly greater than for the medical areas, so are the returns on investment. Indeed,
in 1993, the management of the mental health hospitalizations provided seven times as much
in absolute dollar savings as a surgical case, and 20 times as much as the management of a
maternity case. The article also discusses the implication of full mental health benefits for
health care reform.
Keywords: costs, utilization management
398. Langman-Dorwart, N., Wahl, R., Singer, C. J., & Dorwart, R. A. (1992).
Managed mental health: From cost containment to quality assurance.
Administration and Policy in Mental Health, 19, 345-353.
This article describes the managed care approach of one national managed health care compa-ny
over the past 5 years, with an emphasis on the integration of quality assurance into utiliza-tion
review. Through a case-study approach of this company, the authors explore the ways in
which an emphasis on quality may, in the long run, lead to increased cost-effectiveness and
efficiency. The authors conclude that clinically oriented utilization review can control mental health costs while monitoring and improving quality of care. They anticipate future changes
in mental health cost containment efforts such as increasing reliance on utilization and quality
data, improved match between clients and approved clinicians based on acuity and appropri-ateness
of service, and continued redirection of patients to outpatient settings.
Keywords: quality assurance, utilization management
399. Lewin, R., & Sharfstein, S. S. (1990). Managed care and the discharge
dilemma. Psychiatry, 53, 116-121.
This article describes the ways in which efforts by "fourth party" case managers to contain
costs may lead to premature hospital discharge for severely mentally ill patients. A case study
of a borderline patient exemplifies the potentially deleterious effects of early discharge on
patients such as the "sicker and quicker" phenomenon leading to repeated short-term hos-pitalizations,
pressure to inappropriately use high doses of medicines or electroconvulsive
therapy in order to produce a rapid clinical response, and compromise of treatment goals.
The authors argue that there is an urgent need for outcome studies that justify the costly
treatment in inpatient care for a subset of patients and that document the negative impacts of
premature discharge. Further, they advocate increased reimbursement for community-based
residential care for chronically mentally ill persons.
Keywords: serious mental illness, utilization management
400. Oehm, M. J. (1992). Information systems. In S. Feldman (Ed.),
Managed mental health services (1st ed., pp. 143-164). Springfield, IL:
Charles C. Thomas.
An efficient, reliable, and flexible computer information system can enhance the quality of
utilization management. Despite its advantages, few utilization management companies have
implemented such a system because they prefer "tangible" recordkeeping and fear high costs
and frequent downtime. The author describes the key features of an information system and
how it can address these concerns. The system should be fast and reliable and include data
about patients, providers, benefits, and clinical criteria. Among other features, it should
perform coding and "flag" certain cases, assign case numbers, and automatically transfer
information to the claims system. Although the most effective systems are internally
developed, the author concludes that packaged systems can be successfully adapted for use.
Keywords: information systems, utilization management
401. Panzarino, P. J., & Wetherbee, D. G. (1990). Advanced case
management in mental health: Quality and efficiency combined.
QRB Quality Review Bulletin, November, 386-390.
The case manager in a managed mental health care system can serve as the patient’s
ombudsman to provide high quality care. Treatment effectiveness data, outcome studies,
and utilization patterns, rather than simply availability and cost of treatment, guide case managers’ decision making. There are four steps to the decisionmaking process: preadmis-sion
certification, triage, concurrent review, and individual case management or creative
benefit reallocation. A case example illustrates how these steps can be employed to ensure
a continuum of care in appropriate, cost-effective outpatient programs.
Keywords: case management, utilization management
402. Reinhardt, B., & Shepherd, G. L. (1994). Behavioral health case review:
Utilization review or case management? One company’s view. In S. A.
Shueman, W. G. Troy, & S. L. Mayhugh (Eds.), Managed behavioral health
care: An industry perspective (pp. 76-91). Springfield, IL: Charles C.
Thomas.
This chapter describes the process of managed behavioral health care as it is conducted by
one case management company. The authors focus on (1) the role of the case manager; and
(2) what the case management company can do legally and practically to affect patient treat-ment.
They present some of their own experiences with case management.
Keywords: case management, utilization management
403. Sturm, R., McGlynn, E. A., Meredith, L. S., Wells, K. B., Manning,
W. G., & Rogers, W. H. (1994). Switches between prepaid and fee-for-service
health systems among depressed outpatients: Results for the
medical outcomes study. Medical Care, 32, 917-929.
The authors found that the lowest rate of plan switching was among patients of mental health
specialists in fee-for-service plans, compared to general medical patients in fee-for-service
plans and both types of patients in prepaid plans. Additional findings of this longitudinal
study are presented and discussed.
Keywords: capitation, utilization management
404. Tischler, G. L. (1990). Utilization management of mental health
services by private third parties. American Journal of Psychiatry, 147,
967-973.
In utilization management a third party—rather than the physician—is the final arbiter of
treatment. This article describes three utilization management approaches: preadmission certi-fication,
concurrent review, and case management. Utilization management raises a number
of issues, such as professional bias in treatment, what constitutes an effective community
substitute for inpatient care, the role of utilization management in shifting costs from Federal
to State agencies, the lack of privacy safeguards, quality control, and practitioner liability.
The author concludes that there is a need for further study of the implications and efficacy
of utilization management.
Keywords: utilization management
405. Tischler, G. L. (1990). Utilization management and the quality of care.
Hospital and Community Psychiatry, 41, 1099-1102.
Utilization management has implications for the availability, appropriateness, and effectiveness
of mental health care. This article discusses the history of utilization management in both the
public and private sectors, and the development of peer review approaches to care decision
making. The author identifies clinical and economic factors that influence care decisions, and
suggests ways to determine whether systematic biases exist in reviewer decision making. He
concludes that more research is needed on the impact of cost-containment initiatives on access
and outcome.
Keywords: utilization management
406. Trabin, T. (1994). How will computerization revolutionize managed
care? Managed Care Quarterly, 2(2), 22-24.
This brief article presents an imaginary scenario of how computerization will help clinicians
and case managers access and communicate patient data for behavioral health services in the
near future. The author uses this scenario to demonstrate how computerization of behavioral
health information is revolutionizing the way payers, managed care companies, and providers
use and exchange information. He describes some of the benefits of this advanced technology
and obstacles to attaining these gains.
Keywords: information systems, utilization management
407. Wanerman, L. (1993). Managed mental health for children and
adolescents. New Directions for Mental Health Services, 59, 13-26.
In this chapter, the author uses a series of cases to illustrate the ways in which managed care
can provide comprehensive and cost-effective mental health and substance abuse treatment
for children and adolescents. The author briefly describes the Focused Adolescent and Child
Treatment team at U.S. Behavioral Health (USBH), a national managed care company. The
team includes mental health professionals from a variety of disciplines who work with
providers to coordinate care from intake to referral and continual case monitoring. The
author argues that this approach can protect generally limited and restrictive mental health
benefits so they are available when truly needed. USBH’s guidelines for level-of-care decisions
in mental health for children and adolescents are included in an appendix.
Keywords: children, managed behavioral health care organizations, utilization
management
408. Wickizer, T. M., & Lessler, D. (1998). Do treatment restrictions imposed
by utilization management increase the likelihood of readmission for
psychiatric patients? Medical Care, 36(6), 844-850.
This article describes a 5-year study on more than 2,000 privately insured psychiatric patients
and uses logistical regression analysis to determine how utilization management programs
affected restrictions on length of stay and the likelihood of readmission. The findings indicated that those patients whose length of stay was restricted by utilization management (UM) were
more likely to be readmitted. The authors view readmissions as a sign of poor quality service
and believe UM programs might best serve patient populations by improving clinical outcomes
as well as containing costs.
Keywords: utilization management
409. Wickizer, T. M., & Lessler, D. (1998). Effects of utilization management
on patterns of hospital care among privately insured adult patients.
Medical Care, 36(11), 1545-1554.
Although utilization management (UM) is one of the primary tools of an HMO in cost con-tainment,
there has been little research on the effects of this practice on patterns of care. In this
study, researchers examined pre-admission review and concurrent (continued stay) review of
49,654 privately insured adult patients undergoing utilization review between January 1989
and December 1993. The focus of the study was to examine how often UM denied care at
time of admission, to what extent UM restricted hospital length of stay, which diagnoses and
procedures were most affected by UM, and whether UM became more restrictive with time.
The study found that fewer than 1 percent of patients were denied care at time of admission.
Restricting length of stay through concurrent review accounted for 83 percent of the total
reduction in inpatient care. Utilization management was the most restrictive for mental health
patients, who represented 5.7 percent of the study population but accounted for 54.7 percent
of the total reduction in requested days.
Keywords: utilization management
410. Wickizer, T. M., Lessler, D., & Travis, K. M. (1996). Controlling inpatient
psychiatric utilization through managed care. American Journal of
Psychiatry 153(3), 339-345.
This article reports the results of a study of the effect of utilization management on psychi-atric
hospital inpatient care. The authors analyzed data on utilization management review
activities conducted by a single large commercial insurance carrier during 1989-1992.
Measures included percentage of admission requests approved, number of days requested and
approved, and number of additional treatment days granted. In addition, the authors exam-ined
how the number of days approved by utilization management compared with lengths of
stay of patients with similar diagnoses in the general population as reported by the National
Hospital Discharge Survey. The authors discuss the limitations of the study, and stress the
need for studies on the effects of managed care on patient outcomes and the quality of care.
Keywords: utilization management
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