Hello Tarik Thanks for your informative post, true with the managed care under so much pressure to reduce the costs of their customers’ health care, it is not surprising that Utilization management is gaining popularity not only within the managed care arena but, also within the entire health care industry. The concept of utilization management as has been echoed in various discussions this week is based on encouraging the highest quality of care, in the most appropriate setting while containing the costs of health care. In a nutshell, UM is looking to avoid overuse and underuse of care or services by beneficiaries or providers. Because the utilization management includes a range of processes, its application can be utilized prior
Balance sheet lists assets, liabilities and owner’s equity. The assets listed on the balance sheet are acquired either by debt (liabilities) or equity. “Companies that use more debt than equity to finance assets have a high leverage ratio and an aggressive capital structure. A company that pays for assets with more equity than debt has a low leverage ratio and a conservative capital structure. That said, a high leverage ratio and/or an aggressive capital structure can also lead
Membership Services (MSD) at Kaiser Permanente used to be a modest department of sixty staff. However, over the past few years the department has doubled in size, creating minor departmental reorganization. In addition the increase of departmental staffing, several challenges became apparent. The changes included primary job function, as well as the introduction of new network system software which slowed down the processes of other departments. These departments included Claims (who pay the bills for service providers outside of the Kaiser Permanente network), and Patient Business Services (who send invoices to members for services received within Kaiser Permanente). Due to the unforeseen challenges created by the system upgrade, it was decided that MSD would process the calls for both of the affected departments. Unfortunately, this created a catastrophic event of MSD receiving numerous phone calls from upset members—who had received bills a year after the service had been provided. The average Monday call volume had risen from 1,800 to 2,600 calls per day. The average handling time for each phone call had risen as well—from an acceptable standard of 5.6 minutes to an unfavorable 7.2 minutes. The department continued to be kept inundated with these types of calls for the two years that these changes have been effect.
To guarantee that its members receive appropriate, high level quality care in a cost-effective manner, each managed care organization (MCO) tailors its networks according to the characteristics of the providers, consumers, and competitors in a specific market. Other considerations for creating the network are the managed care organization's own goals for quality, accessibility, cost savings, and member satisfaction. Strategic planning for networks is a continuing process. In addition to an initial evaluation of its markets and goals, the managed care organization must periodically reevaluate its target markets and objectives. After reviewing the markets, then the organization must modify its network strategies accordingly to remain competitive in the rapidly changing healthcare industry. Coventry Health Care, Inc and its affiliated companies recognize the importance of developing and managing an adequate network of qualified providers to serve the need of customers and enrolled members (Coventry Health Care Intranet, Creasy and Spath, http://cvtynet/ ). "A central goal of managed care is containing the costs of delivering care, but the wide variety of organizations typically lumped together under the umbrella of managed care pursue this goal using combination of numerous strategies that vary from market to market and from organization to organization" (Baker , 2000, p.2).
Integrated Managed Care Organization- The organization is properly aligned for the primary driver being cost cutting services. Since all entities within the organization are responsible and affected by any expenses endured on any entity being unfavorable or favorable, the foundation serves as a primary motivator to reduce costs at all levels. This alignment eliminates any financial gains from driving high utilization of services or higher intensity services within the organization. Ultimately, this system allows the physician medical group to drive patient care, being responsible for the clinical care decisions as opposed to health plan making those decisions as designed in other organizations. This is the preferable model for Medicaid
The Crowded Clinic Case Study (Colorado State University - Global, n.d.) discusses the issues of practice management as they apply to access to care. Access to care may be as inconvenient as lengthy patient wait times to issues far more serious that may have a profound effect on the health and well-being of a single patient or an entire cohort.
It is enthralling to note that in spite of the advances in healthcare systems, such as our hospital’s ability to provide patients with lower cost, managed One being the Health Maintenance Organizations (HMO), which was first proposed in the 1960s by Dr. Paul Elwood in the "Health Maintenance Strategy”. The HMO concept was created to decrease increasing health care costs and was set in law as the Health Maintenance Organization Act of 1973, after promotion from the Nixon Administration. HMO would, in exchange for a fee, allow members access to employed physicians and facilities. In return, the HMO received market access and could earn federal development funds.
Since the quality of healthcare would not suffer, the only thing to lose through maximizing efficiency is a bunch of waste. Through its administrative simplification advocacy, the American Medical Association (AMA) claims that up to 14% of a physician’s revenue is taken up by administrative waste. The goal of the administrative simplification is to inspire physician practices to use computerized, instantaneous health plan transactions, minimize manual procedures through the claims revenue cycle, while increasing transparency and reducing vagueness with the payment process involving the insurance company. It is the AMA’s hope to push this movement into high gear, getting more practices on board and to eventually see a decline in wasteful and inefficient administrative
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
At its most fundamental core, quality improvement of healthcare services and resources requires disciplined attention to the measurement, monitoring, and reporting of system performance (Drake, Harris, Watson, & Pohlner, 2011; Jones, 2010; Kennedy, Caselli, & Berry, 2011). Research points to performance measurement as a significant factor in enabling strategic planning processes and achievement of performance goals (Tapinos, Dyson & Meadows, 2005). Thus, without a system of measurement that accounts for the performance behaviors of healthcare professionals, managers and administrative employees, quality improvement remains a visionary abstraction (de Waal, 2004).
The hypotheses in this study indicated that the use of comorbidities along with severity of injury in trauma patients as compared with a severity score alone would help to determine the hospital ranking. The null hypothesis was accepted in this case as there was no difference in the comparison.
In today's health care environment many factors contribute to quality care. As a medical practice manager it is important to provide the best medical service for patients in addition to excellent levels of service. Appointment scheduling is a very important aspect of a smooth running medical practice. Appointment cancellation, no shows, and long waiting time by patients have a negative impact on the efficient running of the practice not only in lost revenue but the practices professional reputation as well (Kruse 2010).
Hospitals recognized the need for the case management model in the mid 1980’s to manage the lengths of stay of hospitalized patients and the treatment plans (Jacob & Cherry, 2007). In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals ...
The present environments for healthcare organizations contain many forces demanding unprecedented levels of change. These forces include changing demographics, increased customer outlook, increased competition, and strengthen governmental pressure. Meeting these challenges will require healthcare organizations to go through fundamental changes and to continuously inquire about new behavior to produce future value. Healthcare is an information-intensive process. Pressures for management in information technology are increasing as healthcare organizations feature to lower costs, improve quality, and increase access to care. Healthcare organizations have developed better and more complex. Information technology must keep up with the dual effects of organizational complication and continuous progress in medical technology. The literature review will discuss how health care organizations can provide effective care by the intellectual use of information.
The health care industry as well as policy makers is hastening to find ways to curtail rising health care costs and reduce lives lost amidst limited health care budgetary concerns.5 Disease management programs have been widely endorsed by both the private and government health sector as a potential solution for addressing growing healthcare costs and improving quality of medical care.1,6
...d procedures are now being monitored to improve clinical processes. Ensuring that these processes are implemented in a timely, effective manner can also improve the quality of care given to patients. Management of the processes ensures accountability of the effectiveness of care, which, as mentioned earlier, improves outcomes. Lastly, providing reimbursements based on the quality of care and not the quantity also decreases the “wasting” and overuse of supplies. Providers previously felt the need to do more than necessary to meet a certain quota based on a quantity of supplies or other interventions used. Changing this goal can significantly decrease the cost of care due to using on the supplies necessary to provide effective, high-quality care. I look forward to this implementation of change and hope to see others encouraging an increase in high-quality healthcare.