How has Utilization Management affected the quality of care?
With an ever-increasing emphasis on reducing costs while still improving patient outcomes, utilization management is taking on new importance. Inpatient care, ideally, is reduced as outpatient resources like home-based care are more frequently explored. However, issues frequently arise over how healthcare professionals are using utilization and review strategies, and even if the efficacy of the system makes it a beneficial tool. Utilization and review policies themselves are frequently attacked as being costly and ineffective. However, as healthcare is now defined, both management and review strategies are likely to remain a part of overall delivery systems, even if modified. Developing a better understanding of how utilization and review policies affect healthcare is important if reducing costs and improving outcomes for patient care are to result.
What is the difference between healthcare utilization and review strategies?
Although the terms utilization management and utilization review are often used interchangeably, they do not represent the same process. Each plays a different role in determining if healthcare is provided in a cost-effective, yet patient-friendly, way. So, what is utilization management? The best utilization management definition encompasses all forms of healthcare services, including all procedures, as well as the determining the optimal use of facilities. The management process is used to ensure patients have appropriate care and are provided all required services to maintain their health without overusing resources.
Utilization review, on the other hand, is retrospective, examining the diagnosis, treatment, and outcomes of patient care with an eye toward improving those functions in future situations. The goal here is to not only guarantee patients are receiving optimal care, but that inpatient procedure are carefully managed to provide better outcomes while, concurrently, managing resources. Careful analysis of patient care allows the development of improvement plans to optimize outcomes for future patients.
How are utilization decisions made?
Since utilization managers generally determine the type and level of treatment a patient will receive, medical professionals cannot afford to ignore the criteria used for preadmission and concurrent review procedures. Typically, the data required will include specific elements, allowing reviewers to verify the treatment recommended matches the conditions present. As a rule, reviewers will consider:
The diagnosis and how it was reached, including the patient’s symptoms and any test results.
A patient’s symptomatology is matched to currently accepted medical necessity standards.
Review of the physician’s determination of medical necessity.
Assuming the patient’s condition and the physician’s determination of medical necessity align with current medical necessity standards, the treatment is approved. If not, the reviewer will communicate the outcome, allowing the physician to examine the findings and appeal, if needed, or revise treatment protocols.
ASSIGNMENT DETAILS:
Provide specific examples to support your thesis, 12PGS. APA FORMAT
