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

Med Care. 1998 Nov;36(11):1545-54. doi: 10.1097/00005650-199811000-00004.


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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Concurrent Review / organization & administration
  • Female
  • Health Services Accessibility / economics
  • Health Services Accessibility / statistics & numerical data
  • Hospitalization / statistics & numerical data*
  • Humans
  • Insurance Claim Review
  • Insurance Coverage / statistics & numerical data
  • Insurance, Health / statistics & numerical data*
  • Length of Stay / statistics & numerical data
  • Male
  • Managed Care Programs / statistics & numerical data*
  • Middle Aged
  • Pregnancy
  • Private Sector
  • United States
  • Utilization Review / organization & administration*