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Adoption of managed care practice arrangements by VHA facilities

Mittman BS, Yano EM, Simon B, Lee ML, Rubenstein LV, Kerr EA. Adoption of managed care practice arrangements by VHA facilities. Paper presented at: VA HSR&D National Meeting; 2001 Feb 15; Washington, DC.


Objectives: The dramatic restructuring of the VHA healthcare delivery system during the 1990s led to adoption of many innovative organizational practices designed to improve system efficiency and effectiveness. The 1999 VHA Primary Care Practices Survey assessed these practices among over 90% of all VHA facilities. We present results regarding 'managed care' arrangements designed to influence and manage utilization and improve quality and appropriateness of care. Methods: A key-informant mailed questionnaire was fielded to all 235 VHA medical centers and clinic facilities with more than 4,000 patients operating during 1999. The questionnaire collected information from a primary care manager at each facility regarding formal organizational policies and practices in primary care, including staffing patterns, decision authority and reporting relationships. Survey questions regarding arrangements implemented to influence clinicians' healthcare service utilization decisions were adapted from Kerr et al's (1994) study of utilization management (UM) practices in private medical groups. Responses to the VHA survey questions were used to create scales assessing VHA facilities' use of 5 specific UM techniques: gatekeeping, pre-authorization, profiling, guidelines and education. Descriptive statistics and bivariate analyses were conducted to examine (1) patterns of use of UM techniques and (2) facility characteristics associated with these patterns. Results: We achieved a 93% response rate. VHA facilities reported highly variable uptake of the 5 UM techniques, with 99% of responding facilities reporting use of gatekeeping (patients require a primary care physician referral for most or all specialty visits) and 95% reporting use of specific methods to voluntarily encourage guideline adherence (e.g., computer reminders, provider education). Fewer VHA facilities actually mandate adherence to guidelines: 35% require primary care providers to follow guidelines when ordering specific tests or procedures. Most VHA facilities (81%) reported use of profiling methods to track outpatient prescriptions, but far fewer monitor utilization of lab tests (41%), specialty referrals (29%) and hospitalizations (27%). These rates are significantly lower than those found among California medical groups, where 71% of surveyed groups require preauthorization for specialty referrals, for example. Conclusions: VHA facilities have adopted a range of techniques designed to influence clinicians' service utilization decisions, with both quality and cost impacts. Overall, the pattern of UM techniques implemented suggests a largely voluntary approach, entailing gatekeeping and guideline dissemination (both encouraged by VHA national policy) and modest levels of profiling. Methods involving more explicit control (e.g., preauthorization and mandated adherence to guidelines) are used less frequently. Observed patterns of UM methods suggest only modest limitations on VHA clinicians' and patients' access to healthcare services, with both cost and quality implications. If effective, voluntary methods such as guideline implementation offer considerable potential for improved appropriateness of clinical decisions, enhancing quality and cost effectiveness. If voluntary adherence to guidelines fail to correct inappropriate decisions, however, then failure to implement more intensive UM methods may result in lost opportunities for both quality and cost performance improvements. Impact: These results provide research, management, and policy relevant insights into current utilization management practices within VHA. Emphases have been on quality improvement and standardization of practice within medical centers over cost containment.

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