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Effects of Utilization Management on Patterns of Hospital Care Among Privately Insured Adult Patients

Wickizer, Thomas M. PhD, MPH*; Lessler, Daniel MD, MHA

Medical Care:
Original Articles
Abstract

Objectives. This study examined the effects of utilization management review activities on patterns of hospital care among a sample of adult patients insured through a managed fee-for-service plan.

Methods. The study was a retrospective analysis of insurance administrative data representing a case series of patients for whom utilization management review was performed. Two review activities were analyzed: pre-admission review and concurrent (continued stay) review. Patients were 49,654 privately insured adult patients reviewed for care between January 1989 and December 1993. Review outcomes included inpatient or outpatient care denied, site of treatment shifted (from inpatient to outpatient), or reduction in requested hospital days (total days requested - total days approved).

Results. Few patients (<1%) were denied care at time of admission or were required to obtain outpatient instead of inpatient care. More common was action taken to limit length of stay by concurrent review, which accounted for 83% of the total reduction (25,197 requested days) in inpatient care. Utilization management became more restrictive with time: the number of days approved declined by 15% to 50% from 1990 to 1993, depending on the type of admission. Utilization management was most forceful in restricting care for mental health patients, who represented 5.7% of the study population but accounted for 54.7% of the total reduction in requested days.

Conclusions. The utilization management program appeared to limit hospital care by managing length of stay once patients were admitted. The effects of restricting length of stay in this manner on quality and health outcomes should be investigated.

Author Information

*From the Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle.

†From the Section of General Internal Medicine, Department of Medicine, Harborview Medical Center and the University of Washington, Seattle.

Supported by a grant (#19977) from the Robert Wood Johnson Foundation.

The opinions and conclusions expressed are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation.

Address correspondence to: Thomas Wickizer, PhD, MPH, Department of Health Services, Box 357660, University of Washington, Seattle, WA 98195-7660; e-mail: tomwick@u.washington.edu.

Received November 18, 1997; initial review completed January 2, 1998; final acceptance April 15, 1998.

© 1998 Lippincott Williams & Wilkins, Inc.