Control over the Utilization of Medical Services

September 1973 | Bruce Stuart, Ronald Stockton

During recent years, the health care industry has been characterized by rapid increases in the volume of services delivered. This escalation is in part unjustified by medical need, and has produced a variety of efforts on the part of payers and providers to restrict overuse. In this article the authors consider the issues and problems involved in the control of medical utilization. Five categories of control are considered in detail: supply limitations, financial disincentives, authorization requirements, review mechanisms, and legal action. The article suggests that the success or failure of these various control mechanisms hinges upon four factors: whose use is being regulated, who performs the control activities, whether the attempted control involves a judgment as to the appropriateness of treatment, and whether the attempt to control occurs before, after, or during treatment. It is concluded that most current forms of utilization control suffer from ambiguity of purpose, organizational inefficiency, and undesirable side effects. The authors offer several proposals to correct these shortcomings, but conclude that the only long-range solution to overutilization lies in a more integrated approach to medical resource allocation and a consequent change in the structure of provider and user incentives.

Author(s): Bruce Stuart; Ronald Stockton

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Volume 51, Issue 3 (pages 341–394)
Published in 1973