Medical professionalism Under Managed Care: The Pros And Cons Of Utilization Review

PROLOGUE: For years physicians have decried the advance of managed care as jeopardizing their clinical autonomy and attacking the very nature of their profession. One medical journal editor recently wrote: “[L]ike no other issue in recent health care history, the ‘managed care movement’ has captured the attention and kindled the emotions of physicians and patients alike Wherever colleagues meet, conversation turns first not to the week's most fascinating case … but rather to the threat of economic survival or to cathartic release of agonies of… ‘intrusion of case reviewers’ or ‘degradation of fee structure’.” In an extensive survey of utilization review firms, the authors of this paper find that managed care can both undermine and reinforce key professional norms. 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.