Medical Professionalism under Managed Care: The Pros and Cons of Utilization Review

Abstract

We contend that the full consequences of managed care for American medicine and health care professionals can be more fully understood if strategies for managing care are identified - in particular, strategies for the administrative oversight of professional decision making. In this paper we apply this perspective to the study of third-party utilization review, making use of a national survey of firms contracting to provide prior authorization for hospitalization in 1992. Survey data suggest that (1) existing approaches to utilization review differ greatly among review firms; (2) review practices that might improve agency and accountability seem to be overlooked by most review firms; and (3) a large number of review firms employ practices that undermine professional autonomy in seemingly inappropriate ways.