Utilization management in healthcare

This concept is not aiming at preventing or stopping treatment, but it is all about ensuring that the appropriate use of health facilities is key. In this way, partakers of the utilization management are tasked to ensure that healthcare as a service is provided with efficiency and in an effective manner. The rapidly rising health care costs stand as the main reason behind the rapid rise and spread of the Utilization management concept. Historical Perspective The American Medical Association (AMA) was formulated in 1847. This was necessitated by the disorganized and poor state of the medical sector in the country. These groups included the Canadian Medical Association, the American Hospital Association and the American College of Physicians. In 1972, there was the formation of the Professional Standards Review Organization (PSRO).

This organ was meant to ensure efficiency and the elimination of unnecessary utilization of the hospital facility. The PRSO was then replaced by the Peer Review Organization (PRO) in 1982. The latter was mandated with the role of validating DRG coding. Utilization Management Programs Taking a further look at Utilization management, there are three common practices that make up the UM concept. The first one is the Utilization Review (UR), then the case management segment, and finally the physician gatekeeper facet. (Wickizer, 2001). The UR segment directs most of its focus on hospital care as well as reviewing outpatient care. The UR program entails a number of services with one of them is the preadmission review. The administrative case management and clinical case management.

The first outlook avails services through brokering thus ensuring that patients acquire the needed cost-efficient services. Clinical case management basically focuses on the optimization of clinical management, besides putting more emphasis on a specified clinical condition like for instance diabetes and cancer. A common thing in these two forms of case management is that they are primarily provided to patients considered as being high risk, and thus may be in need of costly medical attention. Thirdly, the Physician gatekeeping aspect focuses on handling the problem of duplicative and uncoordinated medical provision. " Institute of Medicine. Controlling Costs and Changing Patient Care?: The Role of Utilization Management. Washington, DC: The National Academies Press. doi: 10. Wickizer, T. This review also involves discharge planning, which prepares the patient for the next stage of treatment as he or she leaves the facility.

Retrospective review mainly focuses on the claims made i. e. for purposes of comparing the paid amount and the actual payment for purposes of recovering extra payment. The retrospective review includes the coding review or DRG validation and the appropriate setting (Banatwala and Russo, 2019). Disease Management A system of well-coordinated communications and interventions in a given health care setting, targeting a population that is having a condition which can be immensely improved using patient self-care efforts. Involves the following characteristics; • Development of the physician-patient plan of care and relationship as well Patients are classified on the basis of their risk. • Clinical outcomes, that is, humanistic and economic are evaluated on a continual basis objectively so as to improve the overall health care.