Developing Complying Review Programs under P.L. 93-641: Appropriateness Review.

摘要

A prototype plan for implementing the appropriateness review function under the National Health Planning and Resource Development Act of 1974, P.L. 93-641, is presented. One of the major goals of health planning and development embodied in P.L. 93-641 is to control health care costs. Review of the continued appropriateness of institutional health care services offered in a community or State is required under section 1513 and section 1523 of the law. In the development of an appropriateness review program, it is recommended that agencies consider specific services at the institutional level or services on an areawide basis. The appropriateness review system within a State appears to require an even higher level of structural integration than is the case with institutional health services review / certificate of need. The prototype plan incorporates five sponsoring agencies, a State department of health services and four health systems agencies. It covers hospitals, nursing homes, ambulatory surgical facilities, kidney disease treatment facilities, and health maintenance organizations. Institutional health services for review are categorized under the headings of diagnosis, treatment, and rehabilitation. Six major factors to consider in reviewing the extent to which services meet defined needs are noted: cost, availability, accessibility, continuity, acceptability, and quality. Procedures to follow in appropriateness review are outlined, and criteria, standards, and guidelines for such review are included. Alternative methods of providing services are delineated. Additional information is appended on the prototype plan for appropriateness review.