Abstract
BackgroundWe studied the relationship between physician organization (PO) care management capabilities and inpatient utilization in order to identify PO characteristics or capabilities associated with low inpatient bed-days per thousand.MethodsWe used fuzzy-set qualitative comparative analysis (fsQCA) to conduct an exploratory comparative case series study. Data about PO capabilities were collected using structured interviews with medical directors at fourteen California POs that are delegated to provide inpatient utilization management (UM) for HMO members of a California health plan. Health plan acute hospital claims from 2011 were extracted from a reporting data warehouse and used to calculate inpatient utilization statistics. Supplementary analyses were conducted using Fisher’s Exact Test and Student’s T-test.ResultsPOs with low inpatient bed-days per thousand minimized length of stay and surgical admissions by actively engaging in concurrent review, discharge planning, and surgical prior authorization, and by contracting directly with hospitalists to provide UM-related services. Disease and case management were associated with lower medical admissions and readmissions, respectively, but not lower bed-days per thousand.ConclusionsCare management methods focused on managing length of stay and elective surgical admissions are associated with low bed-days per thousand in high-risk California POs delegated for inpatient UM. Reducing medical admissions alone is insufficient to achieve low bed-days per thousand. California POs with high bed-days per thousand are not applying care management best practices.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-014-0582-5) contains supplementary material, which is available to authorized users.
Highlights
We studied the relationship between physician organization (PO) care management capabilities and inpatient utilization in order to identify PO characteristics or capabilities associated with low inpatient bed-days per thousand
Using fuzzy-set qualitative comparative analysis (fsQCA) we identified a set of medical management practices that California physician organizations use in varying combinations to effectively manage hospital utilization
Summarizing the above results, we found that close PO oversight of patient care from admission to discharge, strong contractual relationships with local hospitalists and hospitals, and effective pre-surgical prior authorization programs are the care management strategies most strongly associated with successful hospital utilization management in delegated POs
Summary
We studied the relationship between physician organization (PO) care management capabilities and inpatient utilization in order to identify PO characteristics or capabilities associated with low inpatient bed-days per thousand. The rates of “never events”, hospital acquired complications and infections, and other facility-related adverse health outcomes remain unacceptably high, despite a concerted effort in the last. Efforts to control health care costs have led to significant shifts in the make-up of the healthcare market since 1980, including the wide-spread adoption of a variety of managed care practices including utilization management, concurrent review, case management, discharge planning, and disease management. Rather than building vertically integrated systems, non-Kaiser health management organization (HMO) plans in California have contracted with independent practice associations (IPAs) and medical groups, paying them capitation to cover the cost of a broad variety of outpatient services (but generally not inpatient services), and delegating them to actively manage inpatient care on the Plan’s behalf [6]
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