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Related Experiment Videos

Managed care is utilization review.

R J Becker1

  • 1HealthCare COMPARE, Downers Grove, IL 60515.

American Journal of Hospital Pharmacy
|October 1, 1990
PubMed
Summary
This summary is machine-generated.

Utilization review (UR) manages healthcare costs by evaluating medical necessity. Despite shifts to outpatient care, effective UR is crucial in all settings to control rising healthcare expenditures.

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Area of Science:

  • Healthcare Management
  • Health Services Research
  • Medical Economics

Background:

  • Healthcare costs continue to rise despite technological advancements and a shift towards outpatient care.
  • The increasing complexity of healthcare delivery necessitates robust utilization review (UR) strategies.
  • UR is implemented across various healthcare settings, including inpatient, outpatient, and mental health services.

Purpose of the Study:

  • To describe the role and evolution of utilization review (UR) within managed care.
  • To examine the drivers and methods of UR in response to escalating healthcare costs.
  • To highlight the expanding scope and anticipated intensification of UR practices.

Main Methods:

  • Review of utilization review (UR) processes and their integration into managed care.

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  • Analysis of UR techniques such as preadmission certification, concurrent review, second surgical opinions, and case management.
  • Examination of the impact of insurance benefit plan redesign on UR implementation.
  • Discussion of the development of practice indicators for prospective treatment planning.

    • Main Results:

    • Utilization review (UR) is a key component of managed care, employed by private organizations, insurance carriers, and healthcare providers.
    • UR strategies have evolved to control hospital service utilization, particularly for high-cost services like inpatient mental health and substance abuse programs.
    • The increasing need for effective UR is driven by rising medical costs and evolving insurance benefit structures.

    Conclusions:

    • Utilization review (UR) is an intensifying aspect of healthcare management, adapting to evolving care delivery models and cost-containment pressures.
    • Improved UR techniques are expected to further refine care management across all organized healthcare settings.
    • The strategic implementation of UR is critical for navigating the complexities of modern healthcare financing and delivery.