Wickizer T M, Feldstein P J, Wheeler J R, McDonald M C
Department of Health Services, University of Washington, Seattle 98195.
Qual Assur Util Rev. 1990 Aug;5(3):80-5. doi: 10.1177/0885713x9000500303.
Utilization review (UR) has become a prominent approach to cost containment now used by almost 65% of private group insurance plans. Although insurers have increasingly relied on UR to contain health care costs, until recently little was known about the effects of this cost containment approach. This article reviews some of the key findings of a UR evaluation, based on analysis of claims data on 223 insured groups for the years 1984 through 1986. The evaluation found that UR reduced admissions by 12%, inpatient expenditures by 8%, and total expenditures by 6%. It was estimated that UR generated net savings of $115 per employee per year. Groups adopting UR with high baseline rates of hospital use had larger expenditure reductions and greater net savings. It appears that UR can play an important role in private cost containment and help improve medical care resource consumption.
利用审查（UR）已成为一种重要的成本控制方法，目前近65%的私人团体保险计划都在使用。尽管保险公司越来越依赖利用审查来控制医疗保健成本，但直到最近，人们对这种成本控制方法的效果知之甚少。本文基于对1984年至1986年223个参保团体的索赔数据的分析，回顾了利用审查评估的一些关键发现。评估发现，利用审查使住院率降低了12%，住院支出降低了8%，总支出降低了6%。据估计，利用审查每年为每位员工节省了115美元的净成本。采用利用审查且医院使用基线率较高的团体，其支出降幅更大，净节省成本更多。看来，利用审查在私人成本控制中可以发挥重要作用，并有助于改善医疗资源的消耗。
