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Journal of Health Politics, Policy and Law 1988 13(4):683-704; DOI:10.1215/03616878-13-4-683
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Duke University Press

Hospital Utilization Review: Past Experience, Future Directions

Danny Ermann
National Center for Health Services Research and Health Care Technology Assessment

Utilization review (UR) programs seek to determine whether specific services are medically necessary and whether they are delivered at an appropriate level of intensity and cost. Although UR programs have been operating for more than 40 years, they have changed dramatically during the past two decades. Today, many health care providers, analysts, and policymakers view UR as a possible solution to hospital inpatient cost and quality problems. This paper addresses how UR has evolved, how UR is used today by different delivery mechanisms (i.e., Medicare, health maintenance organizations, preferred provider organizations, Blue Cross, and commercial insurers), the cost effects of various UR approaches, and how UR will be used in the future.




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