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Related Experiment Videos

Utilization review savings at the micro level.

R K Khandker1, W G Manning, T Ahmed

  • 1Health Economics Research, Inc., Waltham, MA 02154.

Medical Care
|November 1, 1992
PubMed
Summary
This summary is machine-generated.

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Utilization review (UR) programs reduce health care costs. This study shows UR savings vary by employer group

Area of Science:

  • Health Services Research
  • Health Economics
  • Healthcare Management

Background:

  • Utilization review (UR) programs are key to controlling healthcare costs for insurers and employers.
  • Previous studies often used average effectiveness, neglecting variations for specific employer groups.
  • Historical healthcare utilization patterns were underutilized in assessing UR program impact at a micro-level.

Purpose of the Study:

  • To develop a model for estimating the impact of hospital utilization review programs on healthcare utilization for specific employer groups.
  • To analyze how historical utilization patterns influence the effectiveness of UR programs.
  • To enable tailored assessments of UR program effectiveness for individual employer accounts.

Main Methods:

  • Utilized claims data from Aetna Health Plans, covering over 5,300 employer accounts and approximately 580,000 employees.

Related Experiment Videos

  • Analyzed data from 1987 to 1990, identifying employees enrolled in UR programs.
  • Developed an estimation approach to link UR program impact to prior utilization patterns and group size.

    • Main Results:

    • UR program savings were greater for groups with higher prior healthcare utilization due to regression to the mean.
    • Savings were smaller for groups with lower prior utilization.
    • Group size influenced regression to the mean; smaller groups showed greater potential savings by reducing outliers.

    Conclusions:

    • The effectiveness of utilization review programs varies significantly based on employer group's historical utilization.
    • A model accounting for prior use patterns provides more accurate micro-level UR program impact assessments.
    • Smaller employer groups may experience more substantial cost reductions through UR by mitigating outlier cases.