Cost and Utilization Management

Example Project: Implement Managed Care Networks

We were involved in developing and implementing some of the first preferred provider organizations (PPOs) on the west coast for self-insured employers. We contracted with hospitals, physician groups, and solo practice physicians. We worked with third party administrators (TPAs) to administer the PPO network and other cost management programs (e.g., utilization review, large case management, controls for unbundling and upcoding of services). We established fiduciary standards and responsibilities. The initial PPOs were developed in the mid-to-late 1980s. The PPOs provided coverage for about 100,000 self-insured individuals (employees and dependents).

Experience

• Worked with large employers to develop, implement, and monitor inpatient utilization review programs, PPOs and other managed care networks (e.g., mental health networks), large case management and disease management programs, and continuous quality improvement programs.

• Worked with health plans and physician-hospital organizations to evaluate practitioners' efficiency and quality of care, including Allina Medica, Humana Health Plans, Harvard Pilgrim Health Plan, UniHealth America, and Blue Cross/Blue Shield.

• Reviewed cost and utilization management vendor contracts to ensure appropriate transfer of legal risk from employers to vendors, documentation of processes for monitoring program quality and service delivery, wording of risk-sharing agreements between vendor and employer, and contract termination clauses.

• Experienced in the field of group benefits as a practice leader and consultant at two leading employee benefits consulting firms.

• Performed speaking engagements for trade organizations, and published articles on cost and utilization management topics.

• Obtained from the University of California, Los Angeles, a Ph.D. in Health Planning and Policy, and a Masters in Public Health in infectious disease epidemiology--providing a strong clinical, statistical, and methodological background.

Represented Industries and Organizations

Select Topic Public Speaking

International Business Communications/Infoline, Negotiating and Profiting with Risk Contracts, Chicago, Illinois. October 1993. Controlling Increases in the Volume and Intensity of Medical Services.

Human Resources Administration, San Francisco, California. July 1993. Managed Care for Hospitals: Applying Continuous Quality Improvement Principles.

Human Resources Administration, San Francisco, California. July 1993. Managed Care for Hospitals: Applying Continuous Quality Improvement Principles.

International Business Communications/Infoline, Negotiating and Profiting with Risk Contracts, Chicago, Illinois. February 1994. Controlling Increases in the Volume and Intensity of Medical Services.

UniHealth America, Medical Advisory Board, Laguna Niguel, California. May 1994. Improving Performance Through Physician Profiling Systems.

California Medical Association, Quality Management in Ambulatory Care, Newport Beach, California. June 1994. Identifying What to Improve.

American Association of Health Plans, Information Management Conference Exposition, San Diego, California. November 1996. Quality and Information Management Through Claims Data Analysis.

American Association of Health Plans, Information Management and Technology Conference, Orlando, Florida. November 1998. Considerations For Building a Clinical Data Warehouse.

Select Topic Articles

Cave, Douglas G., David Hom, and John J. Mahoney. 1995. Pitney Bowes: Using Comprehensive Cost Information to Build Provider Networks. Benefits Quarterly 11(2), pp. 2-8.

Cave, Douglas G. and Thomas R. Mayer. 1989. Are You Maximizing the Profitability of Your Managed Care Contracts? Newsbrief June/July, p. 15.

Cave, Douglas G. 1989. Analyzing Discretionary Admission Data: A New Approach for Evaluating the Effectiveness of Utilization Review Programs. Compensation and Benefits Management 6(1), pp. 44-48.

Cave, Douglas G. 1989. Direct Contracting With Hospitals: Alternative Payment Arrangements. Employee Benefits Journal June, pp. 26-30.

Cave, Douglas G. 1989. Driving Down Health Care Costs: 1990 Strategies and Solutions. "Analyzing Discretionary Admission Data to Reduce Hospitalization Rates and Length of Stay." Panel Publishers, Greenvale, New York, pp. 217-227.

Cave, Douglas G. and Larry J. Tucker. 1990. Optimizing the Effectiveness of Your Case Management Program. Employee Benefits Journal September, pp. 4-9.

Cave, Douglas G. and Larry J. Tucker. 1991. Preventing Hospital Readmissions: A New Direction for Case Management Programs. Compensation and Benefits Management 7(2), pp. 21-27.

Cave, Douglas G. and John J. Mahoney. 1992. A New Technique for Monitoring Utilization Review Performance. Journal of Compensation and Benefits March/April, pp. 31-34.

Cave, Douglas G. 1992. Managed Care Network Quality: Employer Action Plans. Compensation and Benefits Management 9(1), pp. 1-8.

Cave, Douglas G. 1993. Controlling Increases in the Volume and Intensity of Medical Services. Employee Benefits Journal June, pp. 11-18.

Cave, Douglas G. 1995. Characteristics Needed for Vertically-Integrated Health Systems to Deliver Efficient Medical Services. Compensation and Benefits Management 11(3), pp. 80-82.

Cave, Douglas G. 1999. The PPS/GreenBook: Prevalence Rates and Practice Patterns. St. Louis, Missouri. Practice Patterns Science.

Cave, Douglas G. 2000. Today's Managed Care Market: Benchmark Results for Medical Care Guidelines: Part I. Compensation and Benefits Management 16(1), pp. 57--62.

Cave, Douglas G. 2000. Today's Managed Care Market: Benchmark Results for Medical Care Guidelines: Part II. Compensation and Benefits Management 16(3), pp. 49-54.

Cave, Douglas G. 2001. Today's Managed Care Market: Benchmark Results for Medical Care Guidelines: Part III. Compensation and Benefits Management 16(5), pp. 53-57.





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