Book III: Scientific and Research Applications in Medical Care: Using a Computer to Conduct Utilization and Quality of Care Review in a Prepaid Medical Care Network

摘要

This paper describes how a computerized MIS is used to assist HMO management to conduct utilization and quality of care review activities in a prepaid medical care network. The HMO is a ‘network’ HMO consisting of 5 medical groups, 4 hospitals and a number of other community health organizations. The network currently provides prepaid medical care for approximately 5,000 members. The MIS generates a number of special reports that are used by HMO administration, the HMO medical director and the medical directors of the respective groups to conduct utilization and quality care reviews on a monthly, quarterly and yearly basis. The reports focus on physician office practice styles, physician productivity, service utilization rates, unit cost of care, and specialty referral rates and costs. Monthly and year-to-date utilization, cost and quality of care measures are tracked by the HMO so that the plan and medical group directors are apprised of 1) what physicians are doing, 2) how much it costs, 3) how member groups are utilizing services, and 4) any utilization, cost and quality of care problems that may exist or might occur.