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
According to Harry A. Sultz and Kristina M. Young, the authors of our textbook Health Care USA, medical care in the United States is a $2.5 Trillion industry (xvii). This industry is so large that “the U.S. health care system is the world’s eighth
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.
Ghosh, C. (2013). Affordable Care Act: Strategies to Tame the Future. Physician Executive, 39(6), 68-70.
Kovner, A.R & Knickman, J.R (2011) Jonas & Kovner’s Health Care Delivery in the United States, 10th Edition. New York: Springer Publishing.
Long Term Acute Care Hospital With today’s technology and the specialized skills of doctors, nurses, and therapists, patients who need long term care for acute problems can obtain these services at institutions known as postacute care providers. One type of facility that falls under this title is the Long Term Acute Care Hospital (LTACH) (Munoz-Price, 2009, p. 438). This paper will discuss services provided by LTACHs, the role of the Chief Nursing Officer (CNO) in these facilities, and Medicare reimbursement effected by patient satisfaction surveys. For patients requiring longer acute care than what is generally given at an inpatient acute care hospital, the Long Term Acute Care Hospital is an option. To be admitted to an LTACH, patients are required to have “medically complex situations with a mean length of stay > 25 days” (Munoz-Price, 2009, p. 438 ).
Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives.
Formed in 1998, the Managed Care Executive Group (MCEG) is a national organization of U.S. senior health executives who provide an open exchange of shared resources by discussing issues which are currently faced by health care organizations. In the fall of 2011, 61 organizations, which represented 90 responders, ranked the top ten strategic issues for 2012. Although the issues were ranked according to their priority, this report discusses the top three issues which I believe to be the most significant due to the need for competitive and inter-related products, quality care and cost containment.
Needleman, J., Buerhaus, P., PKankratz, V. S., Leibson, C. L., Stevens, S. R., & Harris, M. (2011). Nurse Staffing and Inpateint Hospital Mortality. The New England Journal of Medicine , 364, 1037-1045.
It is no secret that the current healthcare reform is a contentious matter that promises to transform the way Americans view an already complex healthcare system. The newly insured population is expected to increase by an estimated 32 million while facing an expected shortage of up to 44,000 primary care physicians within the next 12 years (Doherty, 2010). Amidst these already overwhelming challenges, healthcare systems are becoming increasingly scrutinized to identify ways to improve cost containment and patient access (Curits & Netten, 2007). “Growing awareness of the importance of health promotion and disease prevention, the increased complexity of community-based care, and the need to use scarce human healthcare resources, especially family physicians, far more efficiently and effectively, have resulted in increased emphasis on primary healthcare renewal.” (Bailey, Jones & Way, 2006, p. 381).
Niles, N. J. (2011). Basics of the U.S. health care system. Sudbury, MA: Jones and Bartlett.
Miller, J. (2013). Payers rethink utilization costs. Managed Healthcare Executive, 23(11), 9-9,15. Retrieved from http://search.proquest.com/docview/1458614037?accountid=36202
Working in long-term care can be overwhelming. Imagine you are a new graduate nurse putting your new found knowledge and skills to practice for the first time. Your orientation lasted three days which is standard for nurse home orientation compared to hospital orientation that last approximately six to eight weeks for new grads. The shift has just begun and already you have a new admit, new found pressure ulcer to assess, a possible medication reaction, several new orders to take off and eight patients to document on for varying reasons. Feelings of frustration and confusion take over as you are the only nurse on the unit along with a Certified Medication Technician (CMT) and three Certified Nursing Assistants (CNAs) taking care of 47 patients. Ideal nurse-to-patient ratio continues to be a national issue in both the hospital and long-term care setting (LTC). In the LTC setting there is no official nurse-to-patient ratio; there is a suggested staff-to-patient ratio. This issue not only affects the new licensed nurses but the seasoned nurse as well. Recently, there has been controversial debates as to whether heavy workloads are detrimental to patients. The federal, state, and local government regulates many aspects of healthcare. However, it is the physicians, nurses and other healthcare professional that provide care directly to patients. Consequently, does insufficient staffing, heavy workloads, and unsupportive work environment directly contribute to poor patient satisfaction, nurse burnout, high turnover and job dissatisfaction?
Thousands of nurses throughout the nation are exhausted and overwhelmed due to their heavy workload. The administrators do not staff the units properly; therefore, they give each nurse more patients to care for to compensate for the lack of staff. There are several reasons to why
This article is a comprehensive look at staffing on hospital units. It used a survey to look at characteristics of how the units were staffed – not just ratio, but the experience and education level of the nurses. It evaluated several different categories of hospital facilities – public versus private, academic medical centers versus HMO-affiliated medical centers, and city versus rural. It is a good source because it shows what some of the staffing levels were before the status quo of the ratio legislation passed in California. It’s main limitation as a source is that it doesn’t supply any information about patient outcomes.
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 ...