Reviewing the Nature, Necessity, Types, and Problems of Utilization Studies in Health Services to Assess and Control the Consumption of Healthcare Services in Health Insurance Organizations

Document Type : مقاله مروری نقلی

Authors
Masoud Ferdosi 1
Mohammad Reza Rezayatmand 2
Abbas Feizbakhsh 3
Hamid Reza Dehghani 4
Golnoosh Aghili-Dehkordi 5
1 Associate Professor, Health Services Management, Department of Health Services Management, School of Management and Medical Information Sciences AND Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Assistant Professor, Health Economics, Department of Health Economics, School of Management and Medical Information Sciences AND Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Isfahan, Iran
3 General Practitioner, Monitoring and Evaluation Office, Iran Health Insurance Headquarters of Isfahan Province, Isfahan, Iran
4 PhD, Neurosciences, Medical Document Investigation Office, Iran Health Insurance Headquarters of Isfahan Province, Isfahan, Iran
5 MSc Student, Health Services Management, Department of Health Services Management, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
10.22122/him.v15i5.3685
Abstract
Consuming medical services is labeled as utilization. Utilization studies are used by insurance companies to study the behavior of medical service consumers. Currently, insurance companies focus more on caregivers' behavior, and neglect the consumers’ side. This was a narrative review study carried out in year 2018 to emphasize the necessity of utilization reviews and their importance. In this study, we used ProQuest, ScienceDirect, PubMed, Scopus, and ISI Web of Science databases without any time limitation. We chose 50 articles and reviewed them to found 5 essential questions about utilization reviews, and their importance, differences, and challenges, as well as factors affecting them. Our study revealed that having standardized data formats for service providers, integrated data pools, and relevant software sensitive to unusual service consumers, facilitate the utilization review studies.

Keywords

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Health Information Management
Volume 15, Issue 5 - Serial Number 5
Autumn 2018
Pages 247-252