Correspondence
Effect of Utilization Review
N Engl J Med 1996; 334:737-738March 14, 1996
- Article
To the Editor:
In their study of the effect of utilization review in a fee-for-service health insurance plan (Nov. 16 issue),1 Rosenberg et al. found a reduction in the number of diagnostic and surgical procedures performed that required second opinions, but there was no savings in insurance payments. These results were not compared with those achieved in other settings characterized by extraordinary savings in services and money, such as advanced managed-care markets in which utilization review is an important factor.2
In California, the Unified Medical Group Association and various health plans have reported the number of inpatient days for commercial members (those under the age of 65) as being in the range of 240 to 250 per 1000 enrollees per year, with an average stay of 3.5 days per hospital admission in 1989.3 In the study by Rosenberg et al., the average hospital stay was 8.96 days (20,792 inpatient days divided by 2321 admissions) and there were 8425 inpatient days per 1000 enrollees per year in the utilization-review group (20,792 divided by 8 months divided by 3702 enrollees times 12,000). The obvious conclusion should be that utilization review without incentives to providers may not result in substantial savings in a fee-for-service setting.
Current techniques of utilization review are more effective because they are coupled with economic incentives to the medical groups providing the care, and there is a more important role for primary care physicians in helping manage the process. In the study by Rosenberg et al., there was no substantial economic deterrent for physicians to prevent overuse in the utilization-review group.
3 ReferencesLouis Maletz, M.D.
University of California, San Diego, Managed Care, San Diego, CA 92103-85011
Rosenberg SN ,Allen DR ,Handte JS , et al. Effect of utilization review in a fee-for-service health insurance plan. N Engl J Med 1995;333:1326-1330
Full Text | Web of Science | Medline2
Kerr EA ,Mittman BS ,Hays D ,Siu AL ,Leake B ,Brooke RH . Managed care and capitation in California: how do physicians at financial risk control their own utilization? Ann Intern Med 1995;123:500-504
Web of Science | Medline3
Unified Medical Group Association utilization data 1993. Seal Beach, Calif.: Unified Medical Group Association, 1993.
To the Editor:
Because of the measurable effect of second opinions, New York City and its unions expanded their second-opinion requirements. At what cost? Although all the procedures are likely to be much more expensive than a consultation, how much can a consultation cost before the cumulative cost of second opinions concurring with the first (which ultimately save no money, because the procedure is performed in any case) outweighs the savings from second opinions that prevent unnecessary procedures?
Although it is taken as gospel that utilization review reduces the cost to the organization paying for care (that is, the insurance carrier or the health maintenance organization), does it in fact reduce the cost to the ultimate payers, consumers and taxpayers? If the money saved by the intermediary is no longer spent on health care but is redirected to advertising, shareholder profits, and the compensation of executives, there will be a facade of savings with no actual reduction in the overall cost to consumers. If there were no utilization review and the consequent savings were passed directly to consumers, would they be better off? Would the overtreatment resulting from the lack of this disciplinary control be worse for the patient than the undertreatment that may be associated with strict utilization review?
Wolffe Nadoolman, M.B.A.
Yale University School of Medicine, New Haven, CT 06504Author/Editor Response
Dr. Rosenberg replies:
To the Editor: I agree completely with the conclusion Maletz reaches, but some problems with the comparisons on which he bases that conclusion should be pointed out. We analyzed the insurance claims of enrollees who called a utilization-review program about their hospital admissions and ambulatory surgery. The use of health care and costs for a subgroup selected in this way cannot validly be compared with those for an entire insured population, most of whom have no admissions or surgery in a given year. It is particularly misleading to compare the annual rates of inpatient days per 1000 enrollees.
I agree that utilization review is more effective when coupled with economic incentives and an expanded role for primary care physicians. But our study was specifically designed to isolate and identify the effects of this type of review and therefore was structured to exclude these and other factors that affect costs and use of services.
Stephen N. Rosenberg, M.D.
Columbia University College of Physicians and Surgeons, New York, NY 10032
