210class23

210class23 - Stephen Hansell, Ph.D. Department of Sociology...

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Stephen Hansell, Ph.D. Department of Sociology Institute for Health Research http://sakai.rutgers.edu shansell@rci.rutgers.edu 609-203-2830
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Class 23 Managed Care
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A. Explicit rationing 1. Controls on costs (DRG’s) 1. Controls on treatments provided (managed care)
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I. Major features of managed care A. Utilization is monitored B. Pre-authorization of treatment may be required C. Care is limited by third party
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D. Choice of doctor is limited E. Two basic kinds of managed care 1. External utilization review 2. Internal utilization review
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V. Detailed example of external UR for mental illness hospitalization A. Patient shows up at hospital ER in crisis B. Patient presents insurance card C. Hospital calls to verify insurance
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D. Patient admitted for 23 hours for "evaluation" E. First 23 hours F. Discharged after 3-5 days G. Discharged if patient exceeds yearly limits
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III. Internal utilization review A. Similar process B. Except UR occurs within the health care facility
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C. Internal UR is usually a part of a capitated health care plan such as an HMO D. More flexibility because the hospital can pool resources
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IV.
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This note was uploaded on 11/16/2011 for the course 920 210 taught by Professor Hansell during the Spring '08 term at Rutgers.

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210class23 - Stephen Hansell, Ph.D. Department of Sociology...

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