This research provides some of the first empirical data on utilization review—the process in which initial coverage decisions are made—and patients' appeals of denials that result from utilization reviews.
To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life - a group that accounts for more than one-quarter of Medicare's annual expenditures.
A backlash of public opinion against health maintenance organizations in the late 1990s did not result in large numbers of Americans switching to health insurance plans that offer greater consumer choice.
Experts have developed a system for measuring the quality of care delivered to the elderly and used the system to assess the quality of care given to a group of older adults who were members of a managed care plan.
The objective of this study was to test the primary hypothesis that parent proxy-report of pediatric health-related quality of life (HRQL) would prospectively predict pediatric healthcare costs over a two-year period.