Question

Utilization Review and Quality Management

Directions As employers look to control health care costs, MCOs have implemented utilization review protocols to ensure the right care is provided to patients at the right time. At the same time, employers, regulatory agencies and accreditation organizations have increased their expectations that the quality of care increases for patients receiving care through the MCO. In no less than 4 and no more than 6 pages, write a paper that addresses the following: • Define the key elements in utilization review and quality management. • Compare and contrast these two functions and how they have changed over time. • What role does each of these play in managed care? Be sure to think about this from employers who offer coverage to their employees; to regulatory agencies who provide oversight; and to private organizations that conduct external reviews. • In your opinion, do these functions add value to managed care? Support your opinions with examples and your research.

Answer 1

1) Key elements in utilization review and quality management

Utilization Review

It is evaluation of the medical necessicity, appropriateness, and effectiveness in the use health care services, procedures and facilities under the provision of appilicable health care plan.

For example:

If a patient is posted for a surgery under a health care policy, policy company will analysis the patients need for surgery, investigations recommended, and other follow up care cost estimation and compare with their pre-designed procotols of the same type of surgery before its implementation.

a)Reveiw the certificates of medical necessity and refer the medical director for further clarification.

b) Provide concurrent review in clinical reports for the necessity to extending the length of stay for inpatients.

Quality management

It is department in a hospital which acts as overseeing the activities through out the hospital to generate the excellence through determining quality policy, and implement it through quality planning, quality assurance, quality control and quality improvement.

Key functions

A)Improving functions

B) Reducing wastes

C).Engaging staffs

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2) Compare and contrast the two management fuctions

i. The utilization review manager works to provide a appropriate care with the intentions to avoid the unnecessary costs without harming the quality, whereas the quality management focus more on quality with the focus of attracting more consumer and consumer satisfation..

II) Utilization review is done by the external agency outside the hospital, but the quality management is done by the organisation ( the hospital itself)

III) Utilization review works on the basis of prospective review ( review before the care is provided), concurrent review(Review during the care ) and retrospective review ( review after the care was provided). Quality management works on the basis of design, build, deploy, control, measure, review, and improve.

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3. Roles played by utilization review and quality management in managed care.

Utilization Review

I) Avoiding unnecessary expanses.

ii) Decrease the length of hospital stay.

III) Provide continuity of care.

IV) Utilization of all available resourses

v) Accurate documentation

Quality management

I) Identifying and facilitating training opportunities

II) Improves patient satisfaction

III) Helps in the strategic management

IV) Provides room for expansion, growth and profit

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4) Do these functions add value to managed care

I agree these functions help in adding the value to managed care, I support this opinion with the help of following points

I) It reduces the cost of patient care funded by the agencies.

II) It reduces the length of hospital stay.

III) It provides the opportunity to know the patients compliants.

III) It gives the opportunity to know patient expectation.

IV) It allows the organization improve constantly.

V) It allows to provide training in the short comings.

VI) It allows to prevent hospital related complications.