QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:
Home | Help | Feedback | Subscriptions | Archive | Search | Table of Contents

This Article Full Text (PDF) References Alert me when this article is cited Alert me if a correction is posted Citation Map Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Feldman, R. D. Articles by Grogan, C. M. Search for Related Content PubMed PubMed Citation Social Bookmarking                   What's this?

How Will We Use Clinical Guidelines? The Experience of Medicare Carriers

Colleen M. Grogan
Yale University

While support for the development of clinical guidelines is widespread, there is little agreement about how they should be used. Because cost control is the force behind the medical effectiveness movement, the payers' preference, to link clinical guidelines to reimbursement, will likely prevail. We examine the utilization review programs of Medicare Part B carriers and the carriers' attempts to use clinical guidelines to determine medical necessity for the purpose of payment. We find that because the utilization review programs are driven by concerns about cost control, the carriers' actual review process relies on aggregate utilization and spending targets that have little to do with clinical guidelines. The carriers' medical review rhetoric using the terms medically unnecessary and fraud and abuse as synonymsalso highlights their focus on cost control and the lack of concern about why services are used inappropriately.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

This article has been cited by other articles:

				A. L. Hyams, D. W. Shapiro, and T. A. Brennan Medical Practice Guidelines in Malpractice Litigation: An Early Retrospective Journal of Health Politics Policy and Law, June 1, 1996; 21(2): 289 - 313. [Abstract] [PDF]