Managed care and capitation in California : how do physicians at financial risk control their own utilization ?
To describe the structure and range of utilization management methods initiated by physicians in response to capitation..
A large network-model health maintenance organization (133 contracting physician groups) in California..
94 (71%) physician groups caring for 2.9 million capitated patients..
Self-reported use of five major utilization management methods..
All physician groups reported using gate-keeping and preauthorization for certain referrals or tests.
Most also used profiling of utilization patterns (79%), guidelines (70%), and managed care education (69%). Most physician groups asked gatekeepers to submit preauthorization requests for specialty referrals and restricted patient self-referral.
For example, 60% of groups required preauthorization for an intemal medicine subspecialty referral, and 7% allowed patient self-referral.
Most groups also asked gatekeepers to obtain preauthorization for many tests (for example, 95% for magnetic resonance imaging and 53% for pulmonary function tests).
Physicians are responding to capitation by using utilization management techniques, some at early stages of development, that were previously used only by insurers.
This physician-initiated management approach represents a fundamental transformation in the practice of medicine.
Mots-clés Pascal : Organisation, Soin, Technique, Choix, Californie, Epidémiologie, Homme, Médecin, Coût, capitation, Etats Unis, Amérique du Nord, Amérique
Mots-clés Pascal anglais : Organization, Care, Technique, Choice, California, Epidemiology, Human, Physician, Costs, United States, North America, America
Notice produite par :
Inist-CNRS - Institut de l'Information Scientifique et Technique
Cote : 95-0543298
Code Inist : 002B30A04D. Création : 01/03/1996.