Focused utilization review strategies

Researchers from the Michigan Health Care Education and Research Foundation, a research affiliate of Blue Cross and Blue Shield of Michigan, compared three focused utilization review (UR) strategies to determine which method most effectively and efficiently identifies nonacute inpatient hospital admissions. Intensity, Severity, Discharge-Appropriateness (ISD-A) criteria were used to identify nonacute admissions in 8,973 cases in 73 Michigan hospitals. Significant proportions of nonacute admissions were found in medical, psychiatric, and substance abuse cases; surgical admissions had the lowest rates. Strategies involving the concentration ratio were most effective at indicating potential efficiency gains. Focused UR on Diagnosis-Related Groups (DRGs) with nonacute rates greater than 15% captured 41% of admissions and accounted for 85% of nonacute admissions, 85% of nonacute days, and 80% of potential dollar savings. This suggests that UR efforts focused primarily on DRGs with high nonacute rates would significantly improve the efficiency and effectiveness of the overall UR process.