Managed Care and Utilization Management

Utilization management is described as the implementation of guidelines which reduce unnecessary use of medical resources (Kongstvedt, 2007, p.190). There are a variety of methods used to ensure costs are kept at a minimum without compromising patient care. The use of utilization management (UM) are yielding financial benefits resulting in managed care organizations (MCOs) and facilities investing more into UM programs. Health maintenance organization’s (HMOs) use of the primary care physician (PCP) as the “gatekeeper” initially had MCOs view restrictions as a negative approach to patients’ choices. However, some necessary steps have started to be implemented which reduce unnecessary utilization by enforcing some restrictions. The UM applications and tools include: demand management (DM), this refers to various approaches by a health plan to ensure the most effective and necessary plan of care is provided to a patient. DM can be provided by health plans in the form of nurse advice lines. This tool has always been available with the majority of HMO plans. It comprises of nurses that are available to answer questions to members 24 hours a day, seven days a week. This service is now emerging with PPOs, Medicare and Medicaid among others. It benefits the member by reducing trips to the emergency room due to conditions that could easily be treated in a non urgent method (Kongstvedt, 2007, p.192). Nurses have a vital part in UM, a study done by Jencks, Williams and Coleman (2009) showed that Medicare was spending approximately $17.4 billion on beneficiaries who had been readmitted within 30 days of discharge. An additional study done by Bobay, Yakusheva and Weiss (2011) suggested that increased nursing staff prior to the p... ... middle of paper ... ...t Kongstvedt, P. R. (2007). Essentials of managed health care. (5th ed.). Sudbury, MA: Jones and Bartlett publishers. Radzwill, M. A. (2002). Integration of case and disease management: Why and how?. Disease Management & Health Outcomes, 10(5), 277-289. Retrieved from EBSCOhost Wickizer, T. M., & Lessler, D. (2002). Utilization management: Issues, effects, and future prospects. Annual Review Of Public Health, 23(1), 233. Retrieved from EBSCOhost Bobay, K. L., Yakusheva, O., & Weiss, M. E. (2011). Outcomes and cost analysis of the impact of unit-level nurse staffing on post-discharge utilization. Nursing Economic$, 29(2), 69-87. Retrieved from EBSCOhost Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the medicare fee-for-service program. New England Journal Of Medicine, 360(14), 1418-1428. doi:10.1056/NEJMsa0803563
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