Utilization Review and Containment of Hospital Utilization: Some Implications of Providing Care in the Most Appropriate Setting

摘要

The study examines the potential for savings in the use of hospital resources if utilization review policies succeed in curtailing excessive use of hospital facilities. Excessive use is defined as the utilization of hospital care when ambulatory care is medically feasible and acceptable. A utilization review policy would be expected to counteract the substitution of inpatient for outpatient treatment by assuring that all patients with identical medical problems and demographic traits would be treated in an identical least-cost setting regardless of their social and economic circumstances. It might, thus, ascertain that the use of hospital facilities would not be systematically affected by patients' nonmedical or socioeconomic characteristics. Specifically, the study distinguishes between two types of utilization control policies, pre-admission certification and concurrent or continuing-stay review of hospital episodes, and asks how each can contain excessive utilization.