4033.0: Tuesday, November 14, 2000 - 8:50 AM

Abstract #11918

Physician experiences with appeals of adverse utilization review decisions: Implications for patient advocacy

Mark Schlesinger, PhD1, Sarah Hanck2, Deborah S. Cummins, PhD3, Brad Gray, PhD4, and Matthew K. Wynia, MD, MPH3. (1) School of Medicine, Yale University, 60 College Street, New Haven, CT 06520, (2) School of Epidemiology and Public Health, Yale University, 60 College St, New Haven, CT 06511, (3) Institute for Ethics, American Medical Association, AMA Professional Standards Division, 515 North State Street, Chicago, IL 60610, 312 464-5436, deborah_cummins@ama-assn.org, (4) Division of Health Science and Policy, New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029

The patient-physician relationship has fundamentally changed as a result of managed care plans and the pervasiveness of the utilization review (UR) process. Although one ethically appropriate response to an adverse UR decision is to mount an appeal, the frequency and success rates of such appeals are largely unknown. As part of the 1998 AMA Socioeconomic Monitoring Survey, we asked practicing physicians questions regarding the impact of managed care practices on patient advocacy. We collected data on how often physicians had to obtain prior authorization of treatment, how frequently they received denials, and how often these clinicians challenge adverse UR decisions. We found that 80.5% of the sample had to obtain prior authorization. Of these, only 13% reported that they had never experienced a denial of payment for their proposed treatment plans. Among those who had experienced denials, 62% often or always appeal compared to 18% who never or rarely file an appeal. Success in the appeals process was associated with the burden of the review process, i.e., plans that require more time for each appeal were associated with lower reported rates of success by their affiliated physicians. Physicians who were most successful with appeals had been part of the plan for a longer period of time, had a larger percentage of their patients enrolled in their primary plan, and were more experienced in UR processes. This suggests that physicians and patients may benefit from education about the UR process to become more effective patient advocates.

Learning Objectives: The participant in this session will be able to: 1) recognize how managed care has changed the physician's ability to be a patient advocate; 2) identify the factors that contribute to successful outcomes of utilization review and appeals; and 3) understand the need for educational efforts to enable physicians to be better patient advocates in today's system

Keywords: Advocacy, Managed Care

Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: None
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.

The 128th Annual Meeting of APHA