Stephen Hansell, Ph.D. teaches a class on managed care at Rutgers University. The class covers topics such as explicit rationing of care through controls on costs and treatments, major features of managed care including utilization monitoring and requiring pre-authorization of treatments, and limitations of choice of doctors and care under managed care plans. The class also examines examples of external and internal utilization review processes and guidelines such as Milliman guidelines that are used to determine appropriate levels of care.

1. Stephen Hansell, Ph.D.
Department of Sociology
Institute for Health Research
http://sakai.rutgers.edu
shansell@rci.rutgers.edu
609-203-2830

2. Class 23 – Managed Care

3. A. Explicit rationing
1. Controls on costs (DRG’s)
1. Controls on treatments provided (managed care)

4. I. Major features of managed care
A. Utilization is monitored
B. Pre-authorization of treatment may be required
C. Care is limited by third party

5. D. Choice of doctor is limited
E. Two basic kinds of managed care
1. External utilization review
2. Internal utilization review

6. V. Detailed example of external UR for mental
illness hospitalization
A. Patient shows up at hospital ER in crisis
B. Patient presents insurance card
C. Hospital calls to verify insurance

7. D. Patient admitted for 23 hours for "evaluation"
E. First 23 hours
F. Discharged after 3-5 days
G. Discharged if patient exceeds yearly limits

8. III. Internal utilization review
A. Similar process
B. Except UR occurs within the health care facility

9. C. Internal UR is usually a part of a capitated health
care plan such as an HMO
D. More flexibility because the hospital can pool
resources

10. IV. Milliman guidelines
A. Used to decide how much care to approve
B. Milliman and Robertson is most common
1. Write treatment standards
2. Standards limit treatment for each condition

11. C. Examples of Milliman guidelines
D. Guidelines reduce costs for insurance company
E. Physicians don't like Milliman guidelines
F. AMA has fought Milliman guidelines

12. G. Who writes the Milliman guidelines?
H. 4 sets of Milliman guidelines
I. Blue Cross and Blue Shield of NJ use Milliman
guidelines

13. VI. Advantages of managed care
A. Keeps kids out of the hospital
B. Saves big $$ on inpatient treatment

14. VII. Disadvantages of managed care
A. Gamesmanship by docs and hospitals
B. Limited treatment in 5 days
C. Higher workload on physicians
D. Adversarial relationship between hospital staff and
insurance

15. Student Instructional Rating Forms
01:920:210:01
Stephen Hansell
Sociology of Medicine and Health Care

16. Stephen Hansell, Ph.D.
Department of Sociology
Institute for Health Research
http://sakai.rutgers.edu
shansell@rci.rutgers.edu
609-203-2830