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A survey of human resources in managed care organizations.

Although managed health care is increasing exponentially in the United States, minimal published information exists regarding the human resources needed to perform various managed care activities. This article reports on the results of a national survey of managed care organizations regarding the quantitative use of nurse and physician reviewers and the type of activities being performed.

In late 1991, a survey was sent to a random sample of 238 members of the American College of Physician Executives who were based in managed care organizations. The survey requested information as to the type of managed care organization, such as freestanding IPA; PPO; or staff, group, or IPA model of HMO. It also asked for indications of the level of staffing for nurse and physician reviewers, of the timing of onsite reviews, of the activities included in nurse reviewing, and of processes used for credentialing and recredentialing physicians. Utilization of nurse and physician reviewers was based on the number of full-time equivalents (FTE) per 1,000 lives (enrollees) and/or per 1,000 employees (family unit).


Responses were received from 121 (60.5 percent) of those surveyed. Thirty-seven of the responses indicated that the questions were not applicable to their organizations. The remainder of the responses had relevant information and data in most of the areas queried, but not all questions were applicable in every organization.

The largest response (48.2 percent) came from the physician executives in IPA model HMOs (figure 1, page 50). A significant number of responses (22.9 percent) were from organizations that performed managed care activities in more than one model setting.

The average number of full-time nurse reviewers per 1,000 lives (enrollees) was 0.16, with a range from 0.01 to 0.8 (figure 2, page 50). An average of 0.18 full-time nurse reviewers per 1,000 employees (family unit), with a range from 0.01 to 0.6 was determined from the survey (figure 3, page 50). The average number of full-time physician reviewers per 1,000 lives was 0.07, with a range from 0.01 to 0.5. The number was 0.11 full-time physician reviewers per 1,000 employees, with a range from 0.01 to 0.07. (Figures 4 and 5, page 51.) The activities reported varied in relationship to the number of FTE reviewers/1,000 enrollees. Review of the most common response of 0.10 nurse reviewers per 1,000 enrollees revealed a range from 2 to 9 review functions, with the most common response being 7 review activities.

The activities that nurse reviewers performed in managed care organizations are reported in the table on page 51 as percentages of total replies. Almost all organizations (94 percent) reported that their nurse reviewers were involved in precertification. However, only 23 percent reported reviewer involvement with problems of fiscal intermediaries. On-site review was reported as being performed only concurrently in 59 percent of the organizations, only retrospectively in 6 percent, and both concurrently and retrospectively in 35 percent.

The process of credentialing and recredentialing of providers had a variety of responses. Among the processes reported for credentialing are JCAHO credentialing guidelines, hospital credentialing, three references, office survey or on-site review, hospital privileges, employment history, education/training background, board certification/eligibility, CME, DEA and state licensure, malpractice insurance/claims-made history, National Practitioner Data Bank report, and any disciplinary actions, suspensions, or limitations of licensing or privileges. Recredentialing was reported as an updating of credentialing being performed mainly every two years, with a few reporting yearly or every three years. Some replies indicated that performance regarding utilization and quality assessment profiles were included in the recredentialing process.
COPYRIGHT 1992 American College of Physician Executives
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Copyright 1992, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Title Annotation:Managed Care
Author:Trautlein, Joseph J.
Publication:Physician Executive
Date:Nov 1, 1992
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