total health care expenditures, overall use of health services, and attitudes toward medical care.
Although reports of the impact of prior review programs on utilization and cost suffer individually from an array of methodological weaknesses, they present a reasonably consistent pattern of positive results. Taken together, the studies show:
• a substantial initial drop in inpatient hospital utilization following introduction of prior review, with use rates tending to decline at a lesser rate or to level off thereafter;
• an increase in the use of outpatient facilities and physician office services following the introduction of prior review;
• a greater decline in inpatient utilization for reviewed groups than for nonreviewed groups during a period of generally declining hospital use;
• among groups covered by prior review, a more sizable drop in inpatient utilization for groups that started with higher than average initial utilization rates compared with those with lower than average initial utilization rates; and
• a lower rate of increase in the short-term in per-employee medical care costs for groups covered by prior review compared with those that were not, but no long-term reduction in the rate of growth in total medical care spending.
Evidence discussed in this chapter about the effects of prior review programs was discovered through site visits by the committee, computerized literature searches, presentations to the committee, and less formal efforts. The majority of reports take the form of marketing materials, press releases, and client reports prepared by review organizations. Much scarcer are more sophisticated assessments prepared by review organizations or academic researchers.
The earliest studies typically were simple one-group before-and-after studies with no comparison groups. Several recent studies are more methodologically sophisticated, although they too are imperfect. Limitations of available research are described at the end of this section and in the appendix to this chapter.
Most of the early and influential attempts to demonstrate the effects of prior review programs were based on simple before-and-after comparisons.