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  1. Managed care and capitation in California : how do physicians at financial risk control their own utilization ?

    Article - En anglais

    Objective 

    To describe the structure and range of utilization management methods initiated by physicians in response to capitation..

    Design 

    Cross-sectional questionnaire..

    Setting 

    A large network-model health maintenance organization (133 contracting physician groups) in California..

    Participants 

    94 (71%) physician groups caring for 2.9 million capitated patients..

    Measurements 

    Self-reported use of five major utilization management methods..

    Results 

    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).

    Conclusions 

    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

    Logo du centre Notice produite par :
    Inist-CNRS - Institut de l'Information Scientifique et Technique

    Cote : 95-0543298

    Code Inist : 002B30A04D. Création : 01/03/1996.