Utilization management as a

cost-containment strategy by Howard L. Bailit and Cary Sennett

Utilization management (UM) is now an integral part electronic connectivity between payers and providers and
of most public and private health plans. Hospital review, the use of clinical guidelines and computer-based
until recently the primary focus of UM, is associated with decision-support systems, the need for prospective
a reduction in bed days and rate of hospital cost case-level reviews will be reduced. With these changes,
increases. These reductions appear to have had limited UM programs are likely to become more acceptable to
impact on aggregate health care costs because of providers and patients.
increases in unmanaged services. In the future, with

Introduction The rationale for UM rests on three underlying

assumptions:
The great majority of Americans are now enrolled in • In a predominantly fee-for-service payment system
privately or publicly funded health plans that use there is considerable unnecessary and inefficient care
utilization management (UM) programs as a primary provided to patients.
cost-containment strategy. This includes 90 percent of • Unnecessary care can be controlled, saving substantial
privately insured employees and all Medicare and amounts of money and improving the quality of care.
Medicaid participants (Sullivan and Rice, 1991). • The cost of operating UM systems is small compared
Considering that few employees were enrolled in these with the savings.
programs until the middle 1980s, the growth of UM has Extensive literature suggests that perhaps 10 to
been phenomenal. 30 percent of diagnostic tests, procedures, and hospital
Now that UM programs are established, it is an admissions are unnecessary (Chassin et al., 1987;
appropriate time to assess their impact and to reflect on Greenspan et al., 1988; Siu et al., 1986; Winslow et al.,
their future role in the health care delivery system. There 1988a; Winslow et al., 1988b). Whether or not UM can
is an extensive descriptive literature on UM (mainly for control unnecessary care and do it efficiently is addressed
inpatient care), and a small but growing body of in this article.
scientifically rigorous analytic work evaluating its impact Two general aspects of effectiveness are considered:
on utilization, costs, and quality. This literature is briefly Medical care utilization and costs at the program and
summarized here. system levels and the quality of care. (A brief description
The primary concern of this article is the future of of the major UM programs and the history of UM can be
UM. The two critical questions of concern are: Will found in the Technical note.)
externally run public and private UM programs continue?
If so, what changes are expected in UM operations over Individual program utilization and costs
the next 5 to 10 years? This article focuses on the UM
program sponsored publicly for Medicare, or peer review Inpatient medical and surgical review
organizations (PROs), and those operated by UM
companies that do not have a contractual relationship with The impact of PROs on hospital utilization is
physicians and hospitals. UM programs used in health unknown, but it may be limited because only 2 to
maintenance organizations (HMOs), preferred provider 3 percent of admissions are denied (Vibbert 1991b). On
organizations (PPOs), and other network-based managed the other hand, the 1983 diagnosis-related-group (DRG)
care plans are excluded because their effects are payment system gives hospitals the incentive to admit
confounded by the other intrinsic cost-containment Medicare patients more frequently. Nonetheless,
features. Medicare admissions have declined during the past 7
years. Some investigators have posited that this decline
Utilization management programs can be attributed, in part, to the PRO program
(Christensen, 1991; Sloan, Morrisey, and Valvona,
UM as used in this article is: " ... a set of techniques 1988).
used by or on behalf of purchasers of health benefits to Two studies have examined the effectiveness of private
manage health care costs by influencing patient care sector, phone-based hospital admissions and length-of­
decision-making through case-by-case assessments of the stay certification programs using multivariate statistics
appropriateness of care ... " (Institute of Medicine and before-and-after control group design. One study
Committee on Utilization Management by Third Parties, reported reductions in medical, surgical, and psychiatric
1989). bed days per 1,000 employees of 8 percent and in total
health care costs of 6 to 8 percent (Feldstein, Wickizer,
and Wheeler, 1988; Wickizer, Wheeler, and Feldstein,
The views expressed herein are solely those of the authors, and do not 1989; Wickizer, 1990; Wickizer, 1991). Another study of
necessarily reflect the positions of AEtna Life & Casualty. medical and surgical admissions showed a reduction in
Reprint requests: Cary Sennett, M.D., Ph.D., MCI, AEtna Life & bed days of 34 per 1,000 employees per quarter, or
Casualty, lSI Farmington Avenue, Hartford, Connecticut 06156. 13 percent. Inpatient expenses were lowered by

Health Care Financing Review/1991 Annual Supplement 87

8 percent, and total health care costs by 4.5 percent Quality
(Khandker and Manning, 1992).
Compared with telephone-based hospital review, The effect of UM on the quality of care has generated
reductions of another 6 percent in bed days per a great deal of speculation but little serious study. A
1,000 employees and 9 percent in net costs are reported definitive series of investigations has been done on the
when the need for hospital admissions and continued stay impact of Medicare's prospective payment system (PPS)
is reviewed onsite (in the hospital) by nurses (Smith and on mortality and morbidity. The specific effects of PROs
Gotowka, 1991). on quality were not examined separately. Most other
work in this area concerns provider, patient, and
Psychiatric and substance abuse employer satisfaction with UM systems.
PPS and PROs started about the same time. An
Because Medicare has limited mental health coverage, examination of their combined impact on quality provides
PROs have little involvement in managing psychiatric and some insights on the effect of UM programs. Focusing on
substance abuse utilization. For private sector, telephone­ five conditions (acute myocardial infarction, pneumonia,
based UM programs, the one published multivariate study congestive heart failure, cerebrovascular accidents, and
found reductions in length of stay of 20 percent, in hip fracture), a comparison of mortality and morbidity
admission rates of 13 percent, and in net inpatient costs rates before and after the introduction of the (PPS
of 16.6 percent (Gotowka and Smith, 1991). 1981-82 and 1985-86 respectively) showed that PPS was
associated with: an improvement in the process of care
Medical and surgical procedures (Rubenstein et al., 1990); an increase in the percent of
patients discharged in an unstable condition (Kosecoff
Until recently, PROs prospectively reviewed up to et al., 1990); and no differences in 30-day and 180-day
10 surgical procedures using explicit criteria. There is post-admission mortality rates (Kahn et al., 1990). These
little information available on the impact of these data suggest that PPS and PROs have not led to a
reviews, but because they have been discontinued, it is reduction in the quality of care. Little is known about the
apparent that they were not considered to be effective. impact of private sector UM programs on quality.
Many studies in the private sector have assessed the Another dimension of quality is provider, patient, and
effects of second surgery opinion systems, and the results employer satisfaction with UM. There is considerable
are mixed (Leape, 1989). The weight of the evidence provider dissatisfaction with UM programs. Most concern
suggests that these programs are only marginally effective is with the "hassle factor" associated with previously
in controlling costs. autonomous physicians having to justify admissions,
The use of clinical protocols to prospectively assess the length of stay, and procedures to UM companies over the
need for selected tests and surgical procedures is just phone, dealing with review staff who have varying levels
getting started. Denial rates appear to be substantial for of training and expertise and do not know the patient, and
some services, e.g., hysterectomies, 21.5 percent, trying to comply with multiple sets of proprietary clinical
tonsillectomies, 27.1 percent, and minimal for others, rules (Grumet, 1989; Stevens, 1990). These problems are
e.g., cardiac bypass surgery (Vibbert, 1991a). The denial exacerbated by the additional operating expenses
rate across all inpatient and outpatient services averaged associated with UM (Holthaus, 1989; Mayo Clinic,
11 percent. No data are available on net program savings. 1988).
On the other hand, it is clear that most physicians and
Case management hospitals have acquiesced to UM and do comply with
UM processes. The key provider concern now appears to
The one study of case management programs reported be the need to standardize and improve UM systems and
negligible short-term net savings (Henderson, Souder, and operations (Institute of Medicine Committee on
Bergman, 1988). Because of the paucity of studies and Utilization Management by Third Parties, 1989).
the complexities of evaluating case management
programs, any conclusions would be premature. Patients and employers

System level trends Information on patient satisfaction with UM programs

is very limited. Reports by UM companies suggest that
At the delivery system level, hospital precertification patients are generally satisfied (Institute of Medicine
systems are considered to be an important factor in the Committee on Utilization Management by Third Parties,
dramatic reduction (18.6 percent) in the use of 1989).
In general, employers' response to UM have been
community hospital bed days from 1981 to 1988. This
positive, with 73 percent supporting the reviewing of
reduction in bed utilization is associated with a substantial
doctors' treatment decisions as a cost control strategy
reduction in the rate of hospital cost increases (Schwartz
(Health Insurance Association of America, 1991).
and Mendelson, 1991). However, these hospital UM
However, a recent survey by A. Foster Higgins (1990)
programs appear to have had only a modest impact on
total health care cost increases (Schwartz and Mendelson, suggests that employers have some skepticism about the
1991; Chulis, 1991). Apparently, providers responded to effect of UM: A large percentage report that they don't
know if UM programs are effective in controlling costs.
lower bed occupancy rates by increasing utilization of
outpatient tests and procedures and inpatient and
outpatient fees.

88 Health Care Financing Review/1991 Annual Supplement

Future of utilization management Assessing value
From this review of the literature and from the authors' Another reason that UM is likely to continue relates to
personal experience operating UM and managed care the rising demand for accountability and value. With
systems, two questions are addressed: Will payer operated large and growing expenditures for health care, payers
UM continue? If so, what changes are likely to occur in want to know how their money is spent and what it
UM programs over the next 5 to 10 years? produces in terms of health care quality (process and
There are two reasons to believe that publicly and outcomes).
privately operated UM programs will continue. UM can This is in part the result of growing public awareness
make a significant contribution both to managing health of how little is known about the effects of medical
care costs and to assessing the value of health services in procedures and tests on health outcomes, and the
improving health. significant and unexplained variation in practice patterns
among geographic regions and individual physicians.
Managing costs There appears to be greater appreciation that the linkage
between utilization of service and health outcomes is very
Although the number of scientifically rigorous studies complex, and that more services do not necessarily mean
is limited, the available literature indicates that hospital better health.
admissions and length-of-stay precertification programs, The point is that the need for UM goes beyond the
both medical and surgical, and psychiatric and substance issue of controlling costs. UM is a primary approach that
abuse, have led to significant reductions in bed days per public and private payers can use to determine if patients
1,000 employees. The data from individual studies are are receiving appropriate care and if the money spent on
supported by additional evidence from national trends in health care is providing value. With this information,
hospital admissions and length of stay. Clearly, UM payers are in a better position to make informed decisions
systems are associated with major changes in practice about health plan and delivery system changes that will
behavior. lead to greater value.
As to their effect on costs at the individual plan level, In summary, there are good reasons to believe that UM
a few well-controlled studies of hospital review programs will continue. Indeed, UM systems of the general type
report net total health care savings of 4.5 to 8 percent used in the United States may eventually be adopted by
(Feldstein et al., 1988; Gotowka and Smith, 1991; other countries that have controlled health care costs
Khandker and Manning, to be published; Smith and through global budgeting but have little information on
Gotowka, 1991; Wickizer, et al., 1989). Likewise at the the value of the services purchased (Anderson, Sheps,
system level, UM programs are associated with a and Cardiff, 1990; Hurst, 1991).
significant reduction in the rate of increase in hospital
costs during the 1980s (Schwartz and Mendelson, 1991). Utilization management changes
In terms of total health care costs, hospital utilization
review has had less impact. This may be in part a timing What is likely to change in the next 5 to 10 years are
effect, because it is only in the last few years that the the form and content of UM. Most of these changes will
majority of employers have had hospital precertification. be driven by new UM technologies and organizational
Another and more important explanation may be the relationships. Effective UM is dependent on having
substantial increases in utilization for non-reviewed access to detailed clinical information on the care
services, mainly outpatient. proposed or delivered to patients, clinical guidelines that
To deal with this problem, utilization review is now define appropriate care, and positive long-term
being extended to the outpatient setting, and in time relationships with providers.
should lead to significant reductions in utilization rates. UM programs are severely constrained by the lack of
With all the major medical care services under adequate data to support informed and timely decisions
management, it is far more likely that decreased on the appropriateness of care delivered to individual
utilization rates will be reflected in significant reductions patients and to cohorts of patients in a practice or region.
in the growth of health care costs. Moreover, current approaches to collecting data over the
This does not mean that UM will be the primary telephone are complex, physician-time intensive, and
method for bringing health care cost increases down to expensive. This is certain to change in the next few years
socially acceptable levels. Rather, it is an important as providers and payers become linked electronically.
component of a larger managed care strategy that includes This technology is now being installed in hospitals, retail
contracting with or employing a select group of providers pharmacies, medical laboratories, physician offices, and
and having appropriate financial incentives to encourage other delivery settings. Once connected, providers can
them to practice high quality efficient medicine. check patient eligibility, transmit claims, and rapidly and
Further, even with effective managed care, the control efficiently do many UM tasks such as hospital
of health care costs will also require public policies to precertification, thereby reducing much of the
deal with the "macro" level problems of unchecked administrative cost and complexity.
growth of health care technology, facilities, and With electronic data transmission, patient and provider
manpower. Increases in consumer cost sharing may also data bases can be created that span multiple health care
be a necessary component of an overall national cost­ services (e.g., medical, laboratory, pharmacy) in order to
containment policy. Within this context, UM can play a obtain a more comprehensive understanding of the
significant role in improving the efficiency of the delivery appropriateness of the care delivered to individuals and
system. groups of patients over time. With adequate data, UM

Health Care Financing Review/1991 Annual Supplement 89

 systems will be able to identify those specific problem Congruent objectives can be developed in a number of
conditions and providers that need review and those that ways including employment of physicians, as seen in
do not. By targeting reviews, it will be possible to focus staff and group model HMOs and hospitals, or in strong
on a relatively small subset of conditions and providers, supplier-customer relationships. Employment of
thereby reducing the cost of UM. physicians is increasing, but the great majority of
A second development is the establishment of explicit physicians remain self-employed. As such, the challenge
clinical guidelines that define appropriate care. Currently, facing the managed care industry and providers
most UM companies use implicit rules (e.g., physician committed to PPOs and individual practice association
judgment) or simple indication lists to guide UM reviews. (IPA)-model HMOs is to develop supplier-customer
Brook (1991) suggests that decision-tree type guidelines relationships that are long-term and stable.
are needed for about 200 common conditions that More managed care companies appear to appreciate
encompass most of medical practice. Support for this this perspective and are changing their relationship with
view is growing, and many professional groups and network providers. This takes on different forms
Federal research agencies are developing explicit clinical including: decentralizing managed care operations to local
guidelines. markets in order to foster personal relations with
Whether there should be one basic set or multiple sets providers; selecting providers who practice high quality,
of national guidelines remains an issue. There appears to efficient care which reduces the need for case-level
be a consensus that guidelines, although based on general reviews; using UM as an educational rather than as a
medical science, have to recognize limitations in local punitive approach to improving performance; and finally,
medical resources. Moreover, the clinical logic used in making sure that the relationship is profitable for both
guidelines must be available to the providers being parties.
reviewed. Finally, guidelines must allow for rapid Further, as managed care patients become an increasing
decisionmaking, so as not to delay needed care and to percentage of physicians' practices, providers will have a
mitigate the hassle factor. similar incentive to develop long-term relationships with
The requirement for timely UM decisions has limited those managed care companies with whom they have
the quality of the UM process to a greater extent than the congruent objectives and values. If stable relationships
availability of guidelines. Timely reviews require either cannot be developed between independent providers and
that the guidelines be relatively simple or that they be in managed care companies, it is unlikely that IPA-model
computer systems that can negotiate complex clinical HMOs will be able to compete successfully over the long
alogrithms in real-time. For many conditions, the UM run with staff and group-model HMOs.
process will not be very effective using simple rules, so
the key is to build systems that can handle complex Summary
decision rules. With advancements in computer hardware
and decision-support systems, more timely reviews are In less than a decade, UM has grown from a narrowly
possible. focused effort to reduce hospital utilization, affecting only
In this regard, the development of computerized a fraction of the population, to a large set of programs
medical record systems is especially promising. and services that now cover most of the publicly and
Electronic records will have the capacity to include privately insured population. With such rapid growth and
clinical guidelines in the form of decision-support billions spent in development and operations, questions
systems. This technology will allow timely clinical have been raised about the impact of UM on health care
decisions and will change the focus of UM. The need for costs and quality.
prospective case-level reviews will be reduced because Although still in a formative stage, the evidence
provider decisions will be assisted internally. Overall indicates that hospital review, until recently the primary
provider performance can be assessed by retrospective focus of UM efforts, is associated with a significant
review of selected subsets or abstracts of electronically reduction in bed days and the rate of cost increases at
stored clinical data that would be available to payers, both the program and system levels. However, these
reviewers, and others (Detmer, 1991). reductions have, apparently, had limited impact on
It is imperative that managed care companies and aggregate health care costs. As hospital bed days
providers establish congruency in their objectives. This is declined, the cost of unmanaged medical services
the only way that UM programs will be successful using increased. Now, UM is being extended beyond hospitals
the advanced information technology and clinical to include most major medical care services.
guidelines described. To date, many providers view UM UM is likely to continue as an important component of
as an effort to limit their professional autonomy and the national effort to control health care costs and to
income. As a result, attempts to control utilization in one improve quality. In part, this is because UM is an
area of medical care are likely to be countered with important means for assessing the value of health care
increases in volume and prices in other non-regulated services.
areas. There is evidence that this has been the case with In the future, advances in electronic connectivity and
hospital review systems (Schwartz and Mendelson, 1991). the availability of clinical guidelines and computer-based
With congruent objectives, UM can be expected to decision-support systems will reduce the need for
evolve from its current role as a "command and control" prospective case level reviews. Also, many managed care
regulatory program to more of an educational and companies are trying to develop long-term stable
decision-support system for physicians. In this way, UM relationships with providers. With these changes, UM
will be of greater value to practitioners and patients and, programs are likely to become more cost-effective and
as a result, should gain broader support. acceptable to providers, employers, and patients.

90 Health Care Financing Review/1991 Annual Supplement

 There are two forms of procedure certification. Second
Acknowledgments opinion surgery programs require or make available to
We appreciate the constructive reviews of this article patients a second opinion from another physician for 10
by Charles Bell, Bradford Gray, Jacqueline Kosecoff, to 20 elective surgical procedures before they undergo
Lois Maiman, Ronald Parton, and Keith Stevenson. treatment. In most programs, patients have the option of
proceeding with surgery even if the second physician
does not agree with the first.
Technical note Another approach to procedure certification operates in
a similar manner to hospital admissions review. Focusing
Two major attributes that differentiate UM programs on the necessity of expensive inpatient and outpatient
are organizational sponsor and time of review relative to tests and surgical treatments, clinical protocols (also
when care is delivered. called guidelines, algorithms, or parameters) are used to
assist review staff in making decisions.
Review organization sponsor
Concurrent
UM programs differ in purpose and method depending
o? whether they are publicly or privately run. Publicly Concurrent review programs focus on the ongoing care
dtrected UM systems are based on legislation and are not of patients, and thus can intervene to change planned
subject to the same legal constraints (e.g., tort liability, treatments. For hospitalized patients, review organizations
antitrust, malpractice) as privately directed systems. monitor by telephone or by onsite nurses whether patients
Further, in all publicly run systems providers are need hospital-level care. Likewise, for patients with
responsible for initiating and complying with UM catastrophic (e.g., acquired immunodeficiency syndrome)
processes. Patients are usually held harmless for any or chronic (e.g., diabetes) illnesses UM staff work with
penalties caused by failing to comply with UM or for any patients, families, and attending physicians to assist in
retrospective payment denials. In contrast, for private coordinating care. Reviewers can obtain payment for
sector non-network based UM, patients are the non-covered benefits (e.g., home health care) if they are
responsible party. likely to result in more effective or efficient care.
Importantly, for both public and private sector
programs, denial of certification only means the insurer Retrospective
will not pay for (all or part of) the services. Although this
does not prevent the patient from receiving treatment, it These programs assess care after the fact from records
may act as a significant deterrent for expensive services. and claims and have little potential to directly affect care
provided to patients. Retrospective review can influence
patient care indirectly by changing the practice patterns of
Time of review providers faced with retrospective denials. Record
reviews are employed both as a primary review method
Prospective
and as a response to post-treatment appeals from
prosp~ctive or concurrent reviews. Before being paid,
Prospective UM addresses care while it is still being
planned and, consequently, has the capacity to change or submitted claims are monitored to identify and correct
claim coding abuses such as unbundling and code creep.
avert planned treatments. Current systems focus primarily
on the inappropriate use of inpatient facilities and
expensive diagnostic tests and procedures. History of utilization management
Before an elective hospital admission, either patients or
attending physicians call to inform the review Professional standards review organizations (PSROs)
organization that is often represented by a registered were established in 1972 by the Federal government to
nurse. For non-elective admissions, patients and providers provide UM services to Medicare patients but were
are asked to certify within 48 hours of the admission. In terminated in 1982 because of lack of effectiveness
a discussion with attending physicians or their staff, the (Health Care Financing Administration, 1980). In 1983,
review organization makes an assessment if the condition PSROs were replaced by PROs. Federally financed and
is severe enough to warrant hospital level care, and if the regulated but regionally operated by local contractors
expected length of time the patient will be hospitalized (approximately one per State), PROs are responsible for
represents efficient medical practice. Explicit condition­ assuring the quality of services and eliminating
specific criteria are often used to assist in making these unnecessary care.
judgments. PROs focus on reviewing high-volume elective
As with most certification programs, if agreement is procedures, hospital admissions, transfers and
not reached, the case is referred to a review physician readmissions, and DRG "outlier" hospital days. PROs
who can deny certification for the admission. The emphasize retrospective review of records but also do
attending physician and patient have the right to appeal some prospective review of selected procedures. The
the denial. Failure to certify or to comply with the review Omnibus Budget Reconciliation Act of 1986 expanded
decision is usually associated with a financial penalty. ~RO activities to a variety of non-hospital settings,
mcluding ambulatory surgeries, nursing homes, home
health care agencies, and HMOs (Ermann, 1988).
The first privately sponsored UM programs began in
the middle 1960s and focused on hospital utilization.

Health Care Financing Review/1991 Annual Supplement 91

They covered very few employees until the middle to late Gotowka, T.D., and Smith, R.B.: Focused psychiatric review:
1980s (Ermann, 1988), but now include about 90 percent Impacts on expense and utilization. Benefits Quarterly. Fourth
of the 180 million people with private medical insurance quarter, 73-81, 1991.
(Sullivan and Rice, 1991). The review of psychiatric and Greenspan, A.M., Kay, H.R., Berger, B.C., et al.: Incidence
substance abuse and dental services is also widespread. of unwarranted implantation of permanent cardiac pacemakers in
UM for other medical services (e.g., laboratory medicine, a large medical population. New England Journal of Medicine
pharmacy) and settings of care (e.g., physician offices) 318(3):158-163, 1988.
are just beginning. Grumet, G.W.: Health care rationing through inconvenience.
A new industry has developed in the last 10 years to The third party's secret weapon. New England Journal of
provide employers UM services. In addition to the large Medicine 321(9):607-611, 1989.
national insurers (e.g., Metlife, AEtna, and The Health Care Financing Administration: Professional Standards
Travelers) and HMO companies (e.g, Humana Health Review Organization 1979 Program Evaluation. Washington.
Plan, Inc., U.S. Health Care, Inc.) that provide a full Department of Health, Education, and Welfare, Apr. 1980.
spectrum of managed care services, there are about Health Insurance Association of America: Monitoring attitudes
200 companies that only offer UM services (Medical of the public, 1990. Research Bulletin, Apr. 1991.
Utilization Review Directory, 1991). Some of these Henderson, M.G., Souder, B.A., Bergman, A., et al.: Private
companies are national in scope (e.g., INTRACORP, sector initiatives in case management. Health Care Financing
HealthCare Compare), but most are regional or local. Review, 1988 Annual Supplement: 89-95. HCFA Pub.
These companies usually specialize in one area of UM No. 03275. Office of Research and Demonstrations, Health
(e.g., medical and surgical or psychiatric and substance Care Financing Administration. Washington. U.S. Government
abuse) so that it is not unusual for an employer to have Printing Office, Dec., 1988.
contracts with several UM companies. Holthaus, D.: PROs: Peering harder in the '90s. Hospitals,
There is considerable variation among UM companies Feb. 5, 1989.
in the types, qualifications, numbers, and location of Hurst, J.W.: Reform of health care in Germany. Health Care
review staff employed, criteria used to assess clinical Financing Review 12(3):73-86, HCFA Pub No. 03317. Office
appropriateness, level of staff supervision, and ability to of Research and Demonstrations, Health Care Financing
assess and report on program effectiveness (Institute of Administration. Washington. U.S. Government Printing Office,
Medicine Committee on Utilization Management by Third Spring 1991.
Parties, 1989). This variation is likely to be associated Institute of Medicine Committee on Utilization Management by
with substantial differences in UM comp~ny Third Parties: Controlling Costs, Changing Patient Care? The
effectiveness. Role of Utilization Management. In Gray, B.H., and
Field, M.J., eds. Washington. National Academy Press, 1989.
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