Cost Management

  • Volker Eric Amelung
Part of the Springer Texts in Business and Economics book series (STBE)


In healthcare, a variety of different measures and instruments can be applied to manage the cost of healthcare. The following chapter will discuss the usefulness and effectiveness of gatekeeping, formularies and utilization reviews. These three cost management tools are especially relevant to Managed Care. In gatekeeping, most treatment episodes begin with a visit to an individually selected physician, the gatekeeper, who ensures a coordinated and cross-sectorial treatment process. Formularies are used to explicitly define which services are paid for and apply utilisation reviews as a key instrument.


  1. AHNRQ. (2013). Benefits of case management for chronic illness limited. Content last reviewed February 2013. Agency for Healthcare Research and Quality, Rockville, MD. Last accessed March 13, 2018, from
  2. Andersen, R. S., Vedsted, P., Olesen, F., et al. (2011). Does the organizational structure of health care systems influence care-seeking decisions? A qualitative analysis of Danish cancer patients’ reflections on care-seeking. Scandinavian Journal of Primary Health Care, 29, 144–149.CrossRefGoogle Scholar
  3. Berchtold, P., & Hess, K. (2006). Evidenz für Managed Care: Europäische Literaturanalyse unter besonderer Berücksichtigung der Schweiz: Wirkung von Versorgungssteuerung auf Qualität und Kosteneffektivität, Arbeitsdokument des Obsan 16. Neuchatel: Schweizer Gesundheitsobservatorium.Google Scholar
  4. Berchtold, P., & Peytremann-Bridevaux, I. (2011). Integrated care organizations in Switzerland. International Journal Integrated Care, 11(Special tenth Anniversary Edition), e010.Google Scholar
  5. Berchtold, P., Spycher, S. T., & Guggisberg, J. (2004). Evaluation der Telefonberatung durch Medgate – Management summary. Bern: College für Management im Gesundheitswesen.Google Scholar
  6. Blissenbach, H. F., & Penna, P. M. (1996). Pharmaceutical service in managed care. In P. R. Kongstvedt (Ed.), The managed health care handbook (3rd ed., pp. 367–387). Gaithersburg: Aspen.Google Scholar
  7. Bodenheimer, T. (2009). Das Chronic Care Modell auf dem Prüfstand. Care Management, 2(6), 21–23.Google Scholar
  8. Brekke, K. R., Nuscheler, R. & Straume, O. R. (2005). Gatekeeping in health care (CESifo working paper no. 1552), Category 9. Industrial Organisation.Google Scholar
  9. Brown, L. D. (1996). American health care in transition: A guide to the perplexed. Washington, DC: Grantmaker Assistance Program.Google Scholar
  10. Burgdorf, F., & Sundmacher, L. (2015). Potentially avoidable hospital admissions in germany: An analysis of factors influencing rates of ambulatory care sensitive hospitalizations. Deutsches Ärzteblatt International, 111(13), 215–223.Google Scholar
  11. Cassel, D. (2008). Kassenspezifische Positivlisten als Vertragsgrundlage in der GKV-Arzneimittelversorgung. In E. Wille & K. Knabner (Eds.), Wettbewerb im Gesundheitswesen. Frankfurt am Main: Chancen und Grenzen.Google Scholar
  12. Cassel, D., & Friske, J. (1999). Arzneimittelpositivlisten: Kostendämpfungsinstrument oder Wettbewerbsparameter? Wirtschaftsdienst, IX, 529–537.Google Scholar
  13. Chassin, M. R., & Loeb, J. M. (2011). The ongoing quality improvement journey: Next stop, high reliability. Health Affairs, 30(4), 559–568.CrossRefGoogle Scholar
  14. Christianson, J. B., Ginsburg, P. B., & Draper, D. A. (2008). The transition from managed care to consumerison: A community level status report. Health Affairs, 27(5), 1362–1370.CrossRefGoogle Scholar
  15. Cleverley, W. O., Song, P. H., & Cleverley, J. O. (2010). Essentials of health care finance (7th ed.). Sudbury: Jones & Bartlett.Google Scholar
  16. Dixon, T., Shaw, M. E., & Dieppe, P. A. (2006). Analysis of regional variation in hip and knee joint replacement rates in England using hospital episodes statistics. Public Health, 120, 83–90.CrossRefGoogle Scholar
  17. Dranove, D., & Spier, K. E. (2003). The theory of utilization review. Contributions to Economic Analysis and Policy, 2(1), 1–21.Google Scholar
  18. Duncan, I. (2008). Managing and evaluating healthcare interventions and programs. Winsted: ACTEX Publications.Google Scholar
  19. Ferris, T. G., Chang, Y., Blumenthal, D., et al. (2001). Leaving gatekeeping behind – Effects of opening access to specialists for adults in a health maintenance organization. The New England Journal of Medicine, 345(18), 1312–1317.CrossRefGoogle Scholar
  20. Forrest, C. B. (2003). Primary care gatekeeping and referrals: Effective filter or failed experiment? BMJ: British Medical Journal, 326(7391), 692–695.CrossRefGoogle Scholar
  21. Garrido, M. V., Zentner, A., & Busse, R. (2011). The effects of gatekeeping: A systematic review of the literature. Scandinavian Journal of Primary Health Care, 29, 28–38.CrossRefGoogle Scholar
  22. Geraedts, M. (2013). Die ärztliche Zweitmeinung bei der Therapiewahl. In Krankenhausreport 2013, Mengendynamik: Mehr Mengen, mehr Nutzen? Berlin: Schattauer.Google Scholar
  23. Ginzberg, E. (1996). Tomorrow’s hospital. New Haven: Yale University Press.Google Scholar
  24. Gray, B. H., & Field, M. J. (1989). Institute of medicine committee on utilization management by third parties. controlling costs, changing patient care? The role of utilization management. Washington: National Academy Press.Google Scholar
  25. Green, M. A., & Rowell, J. C. (2011). Understanding health insurance: a guide to billing and reimbursement. New York: Delmar Cengage Learning.Google Scholar
  26. Grumbach, K., Selby, J. V., Damberg, C., et al. (1999). Resolving the gatekeeper Conudrum. JAMA, 282(3), 261–266.CrossRefGoogle Scholar
  27. Janus, K. (2003). Managing health care in private organizations. Transaction costs, cooperation and modes of organization in the value chain. Frankfurt am Main: Peter Lang.Google Scholar
  28. Katz, M. (2006). Health care for less. New York: Hatherleight.Google Scholar
  29. Kongstvedt, P. R. (2013). Essentials of managed health care (6th ed.). Burlington: Jones & Bartlett Learning.Google Scholar
  30. Lawrence, D. (2001). Gatekeeping reconsidered. The New England Journal of Medicine, 345(18), 1342–1343.CrossRefGoogle Scholar
  31. Linden, M., Gothe, H., & Ormel, J. (2003). Pathways to care and psychological problems of general practice patients in a “gate keeper” and an “open access” health care system. Social Psychiatry and Psychiatric Epidemiology, 38, 690–697.CrossRefGoogle Scholar
  32. McGlynn, E. A., Asch, S. M., Adams, J., et al. (2003). The quality of health care delivered to adults in the United States. The New England Journal of Medicine, 348(26), 2635–2645.CrossRefGoogle Scholar
  33. Meyer, A. N., Singh, H., & Graber, M. L. (2015). Evaluation of Outcomes From a National Patient-initiated Second-opinion Program. American Journal of Medicine, 128(10), 1138.e.25–11138.e33.CrossRefGoogle Scholar
  34. Mullahy, C. M. (2010). The case manager’s handbook (fourth ed.). Sudbury: Jones & Bartlett.Google Scholar
  35. Mullner, R. M. (2009). Encyclopedia of health services research. California: Sage.CrossRefGoogle Scholar
  36. Payne, S., Restuccia, J. D., Ash, A. S., et al. (1991). Using utilization review information to improve hospital efficiency. Hospital and Health Service Administration, 36(4), 473–489.Google Scholar
  37. Remler, D. K., Donelan, K., Blendon, R. J., et al. (1997). What do managed care plans do to effect care? Results from a survey of physicians. Inquiry, 34, 196–204.Google Scholar
  38. Reuter, W. (1997). Managed care und die pharmazeutische industrie. In M. Arnold et al. (Eds.), Managed care. Stuttgart: Schattauer.Google Scholar
  39. Robinson, R., & Steiner, A. (1998). Managed health care. US evidence and lessons for the National Health Service. Buckingham: Open University Press.Google Scholar
  40. Roland, M., Guthrie, B., & Thomé, D. C. (2012). Primary medical care in the United Kingdom. JABFM, 25(S1), S6–S11.CrossRefGoogle Scholar
  41. Rosenberg, S. T., Allen, D. R., Handte, J. S., et al. (1995). Effects of utilization review in a fee-for-service health insurance plan. The New England Journal of Medicine, 333, 1326–1331.CrossRefGoogle Scholar
  42. Sanofi. (2010). Managed care digest series – HMO-PPO digest 2010–11. Bridgewater.Google Scholar
  43. Sanofi. (2012). Managed care digest series – HMO-PPO digest 2012–2013. Bridgewater.Google Scholar
  44. Sanofi. (2015). Managed care digest series – HMO-PPO digest 2015. Bridgewater.Google Scholar
  45. Schäfer, W., Kroneman, M., Boerma, W., van den Berg, M., Westert, G., Devillé, W., & van Ginneken, E. (2010). The Netherlands: Health system review. Health Systems in Transition, 12(1), 1–228.Google Scholar
  46. Schlesinger, M., Gray, B. H., & Perreira, K. M. (1997). Medical professionalism under managed care: The pros and cons of utilization review. Health Affairs, 16(1), 106–124.CrossRefGoogle Scholar
  47. Schoen, C., Osborn, R., Trang Huynh, P., Doty, M., Zapert, K., Peugh, J. & Davis, K. (2005). Taking the pulse of health care systems: Experiences of patients with health problems in six countries. Health Affairs, Suppl Web Exclusive W5–509.
  48. Schwenkglenks, M., Preiswerk, G., Lehner, R., et al. (2006). Economic efficiency of gatekeeping compared with fee for service plans: A Swiss example. Journal of Epidemiology and Community Health, 60(1), 24–30.CrossRefGoogle Scholar
  49. Shapiro, H. M. (1997). Managed care beware. West Hollywood: Dove Books.Google Scholar
  50. Shi, L., & Singh, D. A. (2012). Delivering health care in America (5th ed.). Burlington, MA: Jones & Bartlett Learning.Google Scholar
  51. Shi, L., & Singh, D. A. (2015). Delivering healthcare in America: A systems approach (Vol. 6). Sudbury: Jones and Bartlett Learning.Google Scholar
  52. Stahl, M. J. (2004). Encyclopedia of health care management. Thousand Oaks: SAGE.CrossRefGoogle Scholar
  53. Stewart, B. A., Fernandes, S., Rodriguez-Huertas, E., & Landzberg, M. (2010). A preliminary look at duplicate testing associated with lack of electronic health record interoperability for transferred patients. Journal of the American Medical Informatics Association, 17, 341–344.CrossRefGoogle Scholar
  54. Sultz, H., & Young, K. (2010). Health care USA: Understanding its organization and delivery. Sudbury: Jones & Bartlett.Google Scholar
  55. Wasem, J., Greß, S. & Hessel, F. (2003). Hausarztmodelle in der GKV – Effekte und Perspektiven vor dem Hintergrund nationaler und internationaler Erfahrungen. Diskussionsbeiträge aus dem Fachbereich Wirtschaftswissenschaften Universität Essen, Nr. 130.Google Scholar
  56. Wennberg, J. E. (2010). Tracking medicine: A researcher’s quest to understand health care. New York: Oxford University Press.Google Scholar
  57. Wickizer, T. M. (1992). The effects of utilization review on hospital use and expenditures: A covariance analysis. Health Service Research, 27(1), 103–121.Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Volker Eric Amelung
    • 1
    • 2
  1. 1.Institute for Epidemiology, Social Medicine and Health Systems ResearchHannover Medical SchoolHannoverGermany
  2. 2.Institute of Health Sciences Research INAV GmbHBerlinGermany

Personalised recommendations