Rethinking utilization review

Article Abstract:

Utilization review of medical care should follow explicit guidelines aimed at improving outcomes as well as lowering costs, and the guidelines should be applied fairly to all patients. Utilization review is the process by which procedures and hospital admissions are reviewed, and is often carried out by insurance companies as a cost-containment measure. A 1995 study compared an actual utilization review to a sham review in which patients had to apply for approval for procedures, but were automatically granted approval. The patients in the sham review group had more procedures than those in the actual review group, but patients in both groups had similar medical expenses and hospital stays. Review boards should compile explicit policies to maximize impartiality in the approval process. Furthermore, patients should participate in formulating these guidelines so that their needs are represented and the process of medical decision making is exposed. Review guidelines should be based on evidence of therapeutic effectiveness as well as cost effectiveness.

Editorial, Management, Evaluation, Medical care, Health insurance, Medical care utilization

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Underuse of Cardiac Procedures: Do Women, Ethnic Minorities, and the Uninsured Fail To Receive Needed Revascularization?

Article Abstract:

Coronary artery angioplasty and bypass surgery are equitably provided, independent of gender, race, or insurance status. Researchers evaluated 631 patients who underwent diagnostic coronary angiography at New York hospitals. Nearly three-fourths of patients who needed surgical treatment received it. Hospitals that did not provide on-site heart surgery were less likely to recommend surgical treatment to uninsured patients.

United States, Care and treatment, Demographic aspects, Medically uninsured persons, Coronary artery bypass, Transluminal angioplasty, Balloon angioplasty

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