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 used to determine need of resources in particular in hospital setting (Murray, 2001). During the review the patient information is shared with payer, who further determines if the particular care is medically necessary corresponding to the terms in the contract between the provider and the payer.
Costs of the care that meets the criteria are certified for the reimbursement. Every American patient, covered by health insurance is exposed to UR. The widespread application of the process made utilization management a significant industry (Murray, 2001). Currently the usefulness and effectiveness of UR process is widely discussed. Hereunder the strength and weaknesses of UR from hospital care perspective are presented. UR as part of the Utilization management process Utilization review (UR) is the process enabling to determine the need of the medical care requested.
Three types of UR are defined: (1) perspective – the rational of the request is determined before the treatment, (2) concurrent – the need is evaluated and approved during the treatment and (3) retrospective – the review of the entire treatment process is taking place after the treatment (cited Corcoran, & VanDiver, 1996). The main aim and strength of the concurrent UR is to ensure that the patient gets right care in timely and cost-effective manner. Effectiveness of the process could be measured by reduced inpatient expenditures (Murray, 2001).
The second strength of concurrent UR could be considered the complex patient care plan, which also includes the discharge plan. The latter covers the care after the hospitalization. The clear inpatient time frame also helps to reduce the treatment costs. The fact that medical decisions in treatment options and the use of resources will be monitors creates a “watch dog” effect and reinforces the selection of the most appropriate option (cited in Rosenberg, 1995). This could be considered as a third strong point of UR. What are the weaknesses or drawbacks of UR process?
One effect of UR could be seen as a drawback or potential weakness. In some cases reviews are seen as jeopardizing the authority and clinical autonomy of the physicians in taking treatment decisions, and by adding a lot of paperwork; UR is attacking the very basis of the medical profession- to serve the patients, not bureaucracy (Schlesinger, Gray, & Perreira, 1997). It also challenges the physicians’ ability to establish treatments options, to view individual clinical needs of each patient as the physicians are threatened with treatment protocols prepared by managed care organizations (MCO).
It reinforces the “cook – book” approach in the treatment and this is not acceptable. To overcome this problem several (MCO) are giving – up the command-and-control approach to UR, are showing more consumer- centred strategies (Kapur, Grescenez, Studdert, 2003). MCO even declare that no review will be made for the decisions taken by the physicians (Murray, 2001). However external review could encourage physicians to think more carefully about treatment options and to discuss these options with their patients. UR also may reinforce accountability in case when an inappropriate practice took place (Schlesinger et al, 1997).