A description study of three competing Health Maintenance Organizations (HMOs) was carried out in Rochester, New York to investigate the relationship between utilization review and hospital utilization rates. / The three HMOs were: (1) Health Watch (HW), a foundation-type plan sponsored by the Monroe County Medical Society, (2) Genesee Valley Group Health Association (GVGHA or Group Health), a centralized prepaid group practice model HMO sponsored by Blue Cross/Blue Shield of Rochester, and (3) Rochester Health Network (RHN), a decentralized group model HMO which had been a series of neighborhood health centers sponsored by the Office of Economic Opportunity (OEO). / The study design accounts for all major alternative explanations for differing hospitalization rates including: age and sex distribution of the enrollees, geographic region, hospital bed supply, physician/population ratios, income, education, availability of alternatives to hospitalization, case mix, service intensity, adverse selection, scope of package benefits, out-of-plan hospital utilization, length of time in operation and financial risk of the physician. / Utilization review was seen as consisting of the utilization review procedures (prospective, concurrent and retrospective) as well as interaction and communication factors which potentiate the effect of the procedures. Interaction factors include those factors which increase the opportunity for plan physicians to interact with one another such as the number of practice sites. Communication factors include those factors which inform the plan physicians about the impact of their utilization decisions such as the type, specificity and frequency of utilization data available to the physician. / Hospital utilization rates, are considered in the aggregate, and for medical and surgical services, by plan. Rates are also considered in their component parts--hospital admissions and average length of stay. / The major finding is that as stringency of utilization review increases, the hospital utilization rate decreases. This relationship holds for all of the years (1974, 1975, and 1976) studied. In addition it was found that the most stringent utilization review are found in group model HMOs and the least stringent in foundation or IPA model plan. / When looked at in more detail, it was found that the more stringent the prospective utilization review procedures, the lower the hospital admission rates. More specifically, the more stringent the surgical prospective utilization review procedures, the lower the surgical admission rates. It had been expected that more stringent concurrent utilization review would be related to lower average lengths of stay, however this relationship was not found. / The study concludes that peer interaction and data feedback are important components of utilization review programs. Medical leadership appears to be important to the development of peer-interaction and the cost-effective orientation of physicians. / The study is important because before the experience of existing HMOs can be generalized, there must be a clear understanding of the way the physician's utilization decision can be brought into line with the objectives of the HMO. / Source: Dissertation Abstracts International, Volume: 42-06, Section: A, page: 2902. / Thesis (Ph.D.)--The Florida State University, 1981.
| Identifer | oai:union.ndltd.org:fsu.edu/oai:fsu.digital.flvc.org:fsu_74519 |
| Contributors | SCHMELING, WINIFRED HALL., Florida State University |
| Source Sets | Florida State University |
| Detected Language | English |
| Type | Text |
| Format | 227 p. |
| Rights | On campus use only. |
| Relation | Dissertation Abstracts International |
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