Effect of utilization review in a fee-for-service health insurance plan.
Although utilization review is widely used to control health care costs, its effect on patterns of health care is uncertain.
In 1989, New York City and its unions temporarily replaced actual utilization review with sham review for half the participants in the city's fee-for-service health insurance plan.
We compared the health services provided to 3702 enrollees whose requests were subjected to utilization review (the review group) with the services provided to 3743 enrollees whose requests received sham review and were automatically approved for insurance coverage (the nonreview group).
The enrollees, physicians, and hospitals were all unaware of the group assignments.
During the study period (mean duration, eight months), the members of the review group underwent 1255 procedures in 20 categories of procedures for which second opinions were required (such as breast, cataract, foot, hernia, and hip-replacement surgery, as well as hysterectomy and coronary bypass surgery), and the members of the nonreview group underwent 1365 procedures (P=0.02).
The members of the review group had 124 fewer procedures in doctors'offices and hospital outpatient departments (P=0.002).
The utilization-review program reduced the number of diagnostic and surgical procedures performed that required second opinions and did not merely del.
Mots-clés Pascal : Economie santé, Assurance maladie, Contrôle, Utilisation, Etude comparative, Etude statistique, Homme, New York, Etats Unis, Amérique du Nord, Amérique
Mots-clés Pascal anglais : Health economy, Health insurance, Check, Use, Comparative study, Statistical study, Human, New York, United States, North America, America
Notice produite par :
Inist-CNRS - Institut de l'Information Scientifique et Technique
Cote : 96-0034105
Code Inist : 002B30A01B. Création : 01/03/1996.