Panel discussion: impact of guidelines on third-party payors and HMOs.

Utilization management (preauthorization) has given way to disease management, i.e., the management, by providers in cooperation with third-party payors, of patients and their disease states from beginning to end. Managed-care organizations are seeking guidelines-based cancer disease management programs that result in: lower, more predictable costs; authoritative quality assurance; measured outcomes; reduced preauthorization disputes; and improved management of cases in clinical trials. Guidelines also need to provide some consistency and consensus regarding the management of common clinical problems. Good guidelines help assist managed-care companies gather data, build a more solid utilization management foundation and support a clinically sound disease management program. Aetna's Institutes of Excellence (IOE) program seeks to address the issue of coverage for high-dose chemotherapy and bone marrow transplantation, but can serve as a useful model for the development of comprehensive cancer networks.

Psychiatrist practice patterns: a comparison of Omaha and Lincoln.

Blue Cross and Blue Shield of Nebraska physician claims data were used to generate and test the hypothesis that there are major differences in psychiatrist practice patterns between the Omaha and Lincoln areas, as evidenced by billing practices. There were extreme differences between the population-based claim rates for the Omaha and Lincoln areas which led to the hypotheses stated above. Provider-based methodology was used to demonstrate that, for Nebraska psychiatrists, as patient load increases, number of charges per patient decreases. Psychiatrists with large market shares for the two respective areas were compared also. Fifty percent of the Omaha psychiatrists with large market shares had a significantly high number of claims per patient, whereas only 25% of the Lincoln psychiatrists (with large market shares) had significantly high numbers of claims per patient. Our hypothesis that there are major differences between Omaha and Lincoln psychiatrist practice patterns was supported. Recommendations include follow-up with the "Patient Satisfaction Survey", continued monitoring, and investigation by the medical community to determine causes for the wide discrepancies in psychiatrist practice patterns.

Nebraska outpatient care quality assessment.

Nebraska Hospital Market Areas (HMAs) with significantly and consistently high admission rates for Ambulatory Care Sensitive Conditions (ACSC) were identified using the Blue Cross and Blue Shield of Nebraska (BCBSN) small area analysis data. Two-thirds of those hospitalized were surveyed by Wiese Research of Omaha, Nebraska to determine if the cause for the high admission rates was related to outpatient care quality. BCBSN members living in HMAs without high admission rates were also surveyed for comparison purposes. The survey revealed that satisfaction with outpatient care was high, and that access (geographic or financial) was not a problem for either the test or control group. The test group did delay (for a short time) obtaining outpatient care when compared to the control group. Most of the control group stated that they obtained outpatient care the day symptoms started. Although the majority of the test group obtained outpatient care within a week, they were not as prompt in obtaining outpatient care as the control group. The types of conditions studied (ACSCS) are conditions that can rapidly become severe, therefore prompt treatment is imperative. The main reason given for chronic delays of both groups were that the condition "suddenly became serious." There may be implications for providers to use more "compliance-gaining" strategies in problem area, and for insurers to offer contract endorsements which would encourage members to obtain prompt treatment and preventive healthcare.