Health Affairs

Another question is the UR effectiveness vs. clinical impact. Some authors question the safety of the UR process and decision making an impact on the quality of care. The denials could be made by non-physicians. The range is from 9% in average reported in one study (cited in Keer et al, 1995) to 37% extent reported in another study (cited in Schlesinger et al, 1997). Reduced length of stay for patients with mental health impairment, showed likelihood in increased readmission within 60 days (cited in Wichizer, & Lessler, 1998).

With regards to safety and medical needs issues, Milstein (1997) presented the study, which showed concurrent data – utilization management resulted in reducing the costs, with no evidence of quality reduction. Also he pointed out, that the main problem regarding safety concerns is the lack of evidence based framework in judging the safety and patient’s acceptability. It is important to note that UR is a costly process, and it requires a great number of qualified nurses, who could deal with the complexity of the process (Murray, 2001).

Coordination between case management and utilization management might be an option in solving this problem (Quick, 1994). In some establishments it’s solved by creating cooperative teams of nurses, social workers and representatives of quality assurance/utilization management. Milstein (1997) argued that UR process has potential in the quality improvement, and if combined with case management could decrease the use of costly resources.

The author concludes that unfortunately this possibility still remains underused. The most important finding of the research presented by Murray (2001) was that particular hospital setting had quite important number of utilization reviews, but a rather low rate of denials – only 1% during the two years period. This suggests that a high level of agreement between the provider and payer is present.

It could also be thought that members of provider staff use appropriate vocabulary while reporting to external reviewer to justify the need of acute care. Further Murray (2001) shares the conclusion, that low denial rates might be the results of mature and professional case management, which is performed by the same personnel who conducts internal UR. The coordination and cooperation between these two services might positively influence hospital care and result in reduce of inpatient costs. Conclusions

Coordination between case management and utilization management may be well considered in some hospitals, it will allow avoiding the duplication of resources the only attention should be paid not to compromise the internal hospital utilization review process. UR should be seen as integral part of quality assurance. Effective process results in cost-saving together with higher quality of care (Milstein, 1997).


Kapur, K. , Gresenez, C. R. , Studdert, D. M. (2003). Managing care: Utilization review in action at two capitated medical groups. Health Affairs, Web Exclusives Chevy Chase, p. W3_275 – W3_282. Milstein, A. (1997). Managing utilization management: A purchaser’s view. Health Affairs, 16(3), p. 87- 90. Murray, E. M. (2001). Outcomes of concurrent utilization review. Nursing Economics, 19(1), p. 17- 23. Quick, B. (1994). Integrating case management and utilization management. Nursing management, 25(11), p. 52 Schlesinger, M. J. , Gray, B. H. , Perreira, K. M. (1997). Medical professionalism under managed care: The pros and cons of utilization review. Health Affairs, 16(1), p. 106- 124.

Utilization review (UR) is the part of utilization management used by managed care industry. It has a task to monitor the use of resources in healthcare, to determine the need of the requested medical care. Concurrent UR is the strategy …

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