Discuss Utilization Management. Define it and discuss its purpose; discuss its components and processes; discuss who is involved in the each step of the processes; discuss the types of measurement used; discuss how it is used for admissions and discharges; and describe the differences between acute care utilization management and chronic care utilization management.
Definition of Utilization Management
Utilization management is evaluating the suitability of medical need and efficiency of health care services procedures and facilities. These have to match the requirements of the appropriate health benefits plan. It describes procedures that are practical and these procedures includes the planning involved before the discharge and other planning such as concurrent planning, pre-certification and clinical case appeals. Besides theses, there are many other processes that utilization management covers. These include concurrent clinical and peer reviews and the requests of the provider, payer or patient are also taken into consideration
Purpose of Utilization Management
The basic purpose of utilization management is to take care and manage the health care cases not only efficiently but cost effectively as well both before and during the health care administration. Both the aspects of managing utilization management are important and if taken care of can bring great success that is beneficial for the patients as well as the physician.
Components and Processes
There are several kinds of processes are involved in utilization management. They include pre-certification review, admission review, continued stay review and discharge planning(Carneal,2000).
Pre-certification Review
For this, a medical certificate is required before a patient can be admitted to an acute care facility or before the patient has to be given the medical services. This process assures that consideration should also be given to all the non-emergency treatments and not just the emergency cases. This determines the suitability of the facilities that are suggested and whether treatment would be suitable on an inpatient or outpatient basis.
Before the patient can formally be admitted to the acute care facility, the patient has to provide his basic diagnostic information to the utilization management personnel. This process is basically for the non-emergency cases and is also known as elective admissions. An elective admission is a planned treatment. This can also be delayed for a particular time period without risk of everlasting disability. These include vasectomies, hernia repairs, hysterectomy, etc.
After a patient has been enrolled, the utilization management coordinator then compares that individual’s request for an elective. The cases that have to be dealt urgently occur the same day as the admission. Pre-certification can be requested by telephone in such cases and the same physician approved reviews the case. On the other hand, the emergency admissions are not subject to pre-certification because in emergency cases the treatment has to be given immediately. If not given, there can be a risk of either permanent disability or even death in some cases. Notification is normally acceptable within 2days of admission. After the notification, the management coordinator reviews the case and then he applies the same physician approved as used in pre-certification
The specific requirements for certification are provided. They can be accessed from the employee’s plan benefit book. This type of review controls the costs before a patient is admitted and even during the stay of the patient. It helps in discharge planning, case management, assistant surgeon review, ambulatory procedure/service review (Wills, 1994).
Admission review
After the admission, next comes the admission review. Both the patient and the service provider i.e. the management care organization would want an early discharge and for this an early discharge planning is required. The acute care facility patients are taken care of. These things are reviewed properly to ensure complete medical treatment that is required to cure the disease so that the patient can be fully satisfied. This would help the patient recover soon from his disease and when things go smoothly it can save many kinds monetary and non-monetary costs for both the parties.
The admission review is performed one the very first working day after the patient has been admitted and the verification of the information received at pre-certification is done. Once the admission is verified, the utilization management process moves on to the next process. During the process of admission review, the acute care utilization management and chronic care utilization management are taken care of accordingly. The patients who have emergency cases are given preference and their reviews are done as soon as it’s possible but for the non-emergency cases, a little delay can be possible as such kind of diseases can be treated later as well without bringing any harm to the patients.
Continued Stay Review
Another name for continued stay review is concurrent review. In this stage, the assessesment of the medical necessity and appropriateness is done and it is applicable to all the admissions. Continued stay review can be accomplished by a cyclic approach. At this stage, the clinical date is compared to the physician approved on a goal based criteria.
It is also used to reduce the number of days a patient has to be kept in a facility while retaining quality of care. Not only this, but it also provides the utilization management coordinator with an opportunity to look forward to an alternative, less acute, care settings, discharge planning needs, and to identify cases with the potential for terrible case management services. This review is all clear to the patient unless there is need for the patient to be involved in discharge planning.
The review mostly just involves the physician who has treated the patient and or the utilization review department. But this process is labor intensive as it requires much information about the case involved. This information is mostly gathered though phone calls as the telephone are used as the main medium to collect information of a patient. Continued Stay Review is conducted until the patient is discharged.
Discharge planning
In this process, the utilization management coordinator coordinates the transfer of the patient from the acute care setting to a different place that is a more appropriate care setting. A more appropriate setting may be a skilled nursing facility, home health care, or a rehabilitation center and an effective discharge planning is implemented at pre-certification review notification.
After a patient has been discharged, the discharge planning coordinators also makes arrangements for continuing care of the patients as in some cases the disease is so acute that the after treatment care is also required. This facility is only given to such patients who need care even after the treatment. However, this facility is only available after the patient is discharged. The plans have to be made in advance as it is extremely important for both the patients and the plan sponsor because delays in discharge are costly to both and so it would be advantageous to both if these things are taken care of before hand.
Discharge planning is most effective when benefit plans include requirements for additional skilled nursing facilities, hospital, home health care and financial incentives so that choices can be made. Other than this the coverage for these services should be taken care of so that excess use of these services would not be made.
Retrospective review
In this process a provider requests for a determination of payment for the services that have already been provided to a Medicare Member. However, the issuance of any formal kind of denial has not been made. Usually, the request for a Retrospective Review is made by means of a claim. A claim is submitted after the medical treatment has been given but before the settlement of the claims. Retrospective Review is mostly needed only when the provider’s late or failed notification is received stating so. The purpose of this policy is for the determination of the criteria when a Retrospective Review may be performed.
After the patient has been discharged, the retrospective review applies the same process and goal based criteria as continued stay review. It is one of the processes that is not preferred to carry out utilization management. Therefore, its used only when its extremely essential. The bad part about this process is that both the patient and provider may not know until several months that services will not be covered.
Discuss Disease Management. Define it and discuss its purpose; elements of disease management; population identification; point of entry; outcomes measurement; member benefits and incentives of participation; certification and accreditation. Discuss why disease management is important.
Definition of Disease Management
Disease management is a strategy of carrying out health care services using interdisciplinary clinical teams, continuous analysis of relevant data, and cost-effective technology. This helps to improve the health outcomes of patients who have some specific diseases. It also includes self-care management techniques, providing education to the patients, and training to the provider. It also provides care plans to persons on individual basis and clinical guidelines are given to the patients to manage the treatable chronic diseases. Other names given to disease management are demand management and health management programs (Gillespie, 2002).
Purpose of Disease Management
Its purpose is to reduce the costs involved in health care and also the quality of life of the people chronic diseases either by preventing or at least reducing the effects of a particular disease (Kongstvedt, 2007).
Elements of Disease Management
Business cases are used to classify the economic and health outcome benefits but they have to be correctly verified. CDM structured collaborative are necessary for training and support. Collaboratives consist of teams led by doctors while the participating practices focuses on complete patient care that includes observance to clinical practice guidelines, use of flow sheets and other tools to facilitate planned patient visits and monitoring the performance of the patients. Patient registries are useful for many problems such as diabetes, asthma, hypertension, depression and heart failure, etc.
Performance measures are very important to know the results of the improvement in health of the patients, patient satisfaction, costs and utilization of health services. Both private and public partnerships with the pharmaceutical companies are essential for the implementation of chronic disease management.
Professional Development of the physicians to augment skills in self-evaluation, patient self-management coaching, and for the use of PDA technology in their practice. Access to the web is also very important for both the patients and the practitioners to manage the flow of information such as having a secure web site for practitioners providing information to help manage the care of their patients. Shared care model is another element. It includes support of general practitioners by specialists. Self-management training and supports for patients, and the contribution of the patients can be judged by doing surveys.
Population identification
Population identification of the individuals having chronic disease can be done by the help of the employer sponsored health plans. (David, 2005). The employer should ensure that the employees have proper and regular health check ups so that if they have any disease it can be straight away treated and not delayed. This would save the monetary costs and the time cost as well and would also reduce the stress that is encountered by the patients in case of emergency cases.
Point of entry
Diseases can be identified by its symptoms. Once the symptoms of a disease are identified, it has to be cured but there can also be some diseases that do not have any particular treatment and is varied from patient to patient. So, all this have to be looked for.
Outcomes measurement
Some of the disease management systems believe that reductions in longer term problems may not be measurable today, but this may be justified later by the continuation of disease management programs until better data is available in 10-20 years (Gillespie & Rossiter, 2003).
Member benefits and incentives of participation
Employers start up with disease management programs for improvement in the health of their employees so this is definitely beneficial for the employees. This not only develops good health but better attitude as well. This not only increases productivity but decreases the insurance costs as well that is beneficial for the employer and the employee.
Other than this, the disease management programs can complement primary care given to the patients by the doctors. Looking at an example we might see that when a patients gives visit to his doctor, he is usually told about the disease he has and do not get much time to talk to the doctor and the patient would be given a pamphlet and some medicine. The doctor would ask the patient to follow a special diet for a particular time period after which he would be asked by the doctor to see him again. However, the patients mostly need more support than just this (Dandalides, personal communication, 2002).
However disease management helps people to understand their diseases and treatments not only in a much better way but it also supports good health behaviors of the patients when they give visits to the doctors and this also increases the success factor among the patients as the patients get a much better chance to follow the instructions made to them by their doctor.
Not just this, but disease management programs can also help to keep track of the usage of the medicines. Patients prefer getting individual attention more often than just seeing the doctor once a month or so. Therefore, it would be better if the prescription being given to the patients is being refilled every month instead of getting a new prescription after six to seven months. This can also help to determine the progress of a patient or make aware of a danger if there is any. Only when a patient has got information and details about the disease, he can make better health care decisions.
Daniel Gold, the director of research for Stay Well Health Management Systems in St. Paul, Minn says they focus more on disease self-management and that the company has its own staff nurses. They also have dietitians and health educators, who conduct special programs that are based on mail, telephone and on-site classes. This is beneficial for individuals to control their conditions as such programs create awareness and help them gain knowledge and skills to be able to manage their health conditions in a better way. They also follow the recommendations of the health care provider and take care of their medication and the diet they take (Atkinsonm, 2002).
Certification and accreditation
Based on the performance, the certification and accreditation is given to MCO’s. There are basically three types of accreditations. Full Accreditation is highest status of accreditation and is given to the organizations that meet or exceeds the standards. Next comes One-Year Accreditation that awards a status of One-Year Accreditation to organizations that meet most accreditation standards but must take further action to achieve Full Accreditation.
Next is Provisional Accreditation that is given to the organizations that meet some, but not all the basic accreditation standards but must take significant action to achieve Full Accreditation (within 12 months).Some are also denied accreditations Such organizations are only those that do not meet the requirements during the Accreditation survey.
Importance of disease management
More and more people are getting attracted to disease management and that shows its significance and importance as it is beneficial for both the employer and the employee. It saves insurance costs and increases productivity of an organization. Although the disease management is a new idea, almost 44 percent of employers offer disease management for chronic medical conditions. According to the Pharmacy Benefit Management Institute, this rate increased from 14 percent in 1995 to 44 percent. (Atkinson, 2002).
Members of the disease management team are divided into three categories that are the high-risk individuals, medium-risk individuals and low-risk individuals. The high risk-individuals are the name suggests get more attention and care than other two category members. They contacted frequently and at times mostly on telephones are also visited by someone at their homes to monitor their medical health such as blood pressure or glucose level checks, etc. Medium-risk individuals are just contacted frequently on the telephone while the low-risk individuals are contacted by mails and occasional telephone contact.
Discuss Quality Assurance. Define it and discuss its structure and processes. Discuss outcomes measurement, peer review, and the governing authorities on QA.
Definition of Quality Assurance
Quality Assurance is a designed in a methodical way and is a set of activities that guarantees that the variances in processes are clearly identified, reviewed and improvement of the defined processes. This fulfills the requirements of customers and product or service makers (Samantha & McGehee, 2002).
Structure and processes
The two most important elements of quality assurance plan are quality control and quality assessment. Quality control makes sure that the quality is maintained until the product reaches its final stage using some appropriate measures and procedures while quality assessment monitors quality control procedures. It further assesses the quality. (van der Heijde 1987). Mostly the processes involved are more qualitative than quantitative in nature.
Outcomes measurement
There are basically two approaches that can be used for outcome measurement. The first one is the measurement of the outcome of the process and the other is based on measurement of the variation of the process. The first approach can be appropriate for any process, but it generally requires extensive efforts foe the collection of the data after which the date has to be analyzed. Using the other process,direct measurement of variability can be done.Its distribution is constant and can be characterized by repetitive measurements but it is more limited in application though it’s also advantageous in order to plan, design, assess, and optimize process performance before the routine operation.
Peer review
Another name for peer review is refereeing. Peer review is the a kind of research in which another person add his ideas to other people’s work who also belong to the same field of work. Although it adds up quality to work but it has also received criticism as it is a slow process and can be misunderstood as well. It is basically the screening of the manuscripts already submitted.
It is not always easy for the other party to spot out mistakes or any kind of flaws in the work already done. Even they might ignore those faults. However, this depends on the experience and expertise they posses. But mostly showing the work to other party, the weaknesses can always be identified and suggestions for improvement can be given. These reviewers are mostly independent and anonymous.
Peer reviews are carried out when the works of the author are sent to the experts in the same field. The experts who do these peer reviews are also called reviewer and this process takes place through e-mail. Quality assurance reviews differ from peer reviews in some ways of the criteria set out for the two. The first one is consistency followed by correctness, coherence, clarity, conformance and concordance. (Adams, 1998)
Governing authorities on Quality Assurance
The reason of this rule is to highlight the minimum governing authority requirements that a program must meet in order to be certified or licensed. Not just every organization can be given a certificate to run its services. Only those that meet up the standards and the criteria of the governing authorities can be given permission so that the highest standards can be promoted. The effective and efficient use of resources should be taken care of and its obligations should be fulfilled.
The organizations should be made accountable to the governing authorities and their should be a check kept on them so that the organizations provide best of their services. For this the governing authorities should the evaluate at regular intervals and in any case when any organization does not meet their standards, they should be given a warning before taking any action. After the assessment of the quality of services the governing authority thinks fit of findings arising out should be allowed to continue.
These checks should not be just once or twice but should be carried out on timely basis for a review of the effectiveness of the procedures and for the implementation of the findings arising out.
Discuss Member Services. Define it and discuss member services as it relates to the MCO and its member. Discuss the types of services that fall into this category; discuss the components of a complaint process; discuss member rights and responsibilities; discuss performance and quality management of a member services unit.
Definition of Member Services
The people who become member or gain membership are eligible to get some services that the organization has promised. The member service is related to the MCO and its member. A group of medical service providers make up an MCO. It consists of physicians, different kinds of clinics and hospitals and pharmaceutical companies, etc. who work together for the health needs of their members. They have a contract with insurers or self-insured employers. MCO provides a wide variety of managed health care services.
After a person receives a notification that he is entitled for MCO, he will receive information about different MCO plan options to receive the benefits. People might select any plan but they prefer the one to which their doctor belongs.
Types of services that fall into this category (MCO)
There are many small and indistinguishable MCOs and mostly all of them provide the same quality of services to the people who enroll there. The MCOs spends more money on low-cost services such as vaccination and as less as possible on high-cost services such as an open heart surgery. MCO’s have a huge budget for advertising and other facilities. The MCOs specialize in low-cost services or high-cost services and this depends on the type of services they are providing. Therefore, the type of people getting enrolled in the MCO’s depends on their health situation. A person joining the type of MCO depends on the level of risk they have and this market segmentation. (Yin, 1995).
Components of a complaint process
Every company even the one that offers great services have some or the other complaints. There are two important components of a customer complaint process. The customers always expect to get an immediate response therefore; the customer services officers should try their level best to resolve the complaints in the best possible manner. This should also be reported to the upper management so that developing trends can be spotted out.
Other than this, empowerment should be encouraged by the upper management. Reward should be given to the employees for handling the complaints of the customers. This is also very important because this works as an incentive for making an employee work with interest and dedication and to achieve the goals set out by the organization.(Ross, 2005).
Member rights and responsibilities
The members of an MCO are that they should be kept updated with information about their services, benefits, practitioners, and member rights and responsibilities. They should be treated with respect and should have a right to privacy. They should feel free to discuss their health plans with their doctors and should be given appropriate treatment options regardless of cost or benefit coverage. Their complaints, grievances, or appeals should be taken care of by the MCO. They should have full right to select their physician to whom they would be assigned and they should be allowed to inspect their medical records. They can also refuse to refuse to accept any particular kind of treatment being given to them by their physician. They should have full rights to make recommendations regarding the member rights and policies of the organization.
The members also have some responsibilities towards MCO’s. They are supposed to provide the information to the practitioner to the best degree possible and learn and understand their health problems, participate in treatment goals with the practitioner, consider the instructions for care and consider the recommendations made to them. It is their own responsibility to become familiar with and follow plan benefits, policies, and procedures of the MCO, to coordinate their care and to behave in an appropriate manner with the practitioner, staff, and other patients.
In any case when there is any kind of change like a change in the family size, address, telephone number, job status, or other insurance coverage, it should be notified to the MCO within 30 days. They should also notify the MCO about any theft that has taken place or to pay any applicable co-payments after the treatment is done.
MCO’s assists the reporting of claims, provide medical case management services, review treatment requests for appropriateness, facilitate services and review and approve provider payments(Ross, 2005). The person enrolled is contacted by the MCO within 60 days of the earliest date of service billed on the form but late submission of claims results are rejected. Therefore, it is they duty of the person being enrolled to check whether he has sent the claim to the correct address. If so, he would get the payment within two weeks of receipt. In cases when the payment is not received payment within a month, the person enrolled should check the status or should inquire about the delay.
Performance and quality management of a member services unit
The thought of forming MCOs is gaining wide popularity among the people and so many MCO companies have been set up and are also coming up with new ways of satisfying the needs of the consumers. People also compare different MCOs before they take their final decision either to enroll in an MCO as a member or to work as a distributor.
Reference
- Adams, N. H.(1998). Quality Assurance: Good Practice, Regulation, and Law. Volume 6, Number 2, 1 April 1998 , pp. 75-85. Taylor and Francis Ltd.
- Atkinsonm,W.(2002). Making diasease management workV ol. 47, No. 1. Retrieved from http://www.shrm.org/hrmagazine/articles/0102/0102atkinson.asp on August 11, 2008
- Carneal, G.(2000). The Utilization Management Guide.2nd Edn.
- David,A.(2005). DM population identification: Room for improvement. Employee Benefit News. Retrieved from http://www.allbusiness.com/medicine-health/diseases-disorders-endocrine/8008494-1.html on August 11, 2008
- Gillespie,J.L. (2002). The Value of Disease Management: Balancing Cost and Quality in the Treatment of Asthma, Vol. 5, No. 4. Retrieved from http://www.npcnow.org/resources/issuearea/diseasemanagement.asp on August 11, 2008
- Gillespie,J.L. & Rossiter,L.F. (2003). Disease Management & Health Outcomes, Vol. 11, No. 6.
- Kongstvedt, P.R. (2007). Essentials of Managed Health Care. 5th Edn.Jones & Bartlett Publishers.
- Ross,G. (2005). Why You Should Have A Complaint Process In Place. Retrieved from http://www.allbusiness.com/sales/customer-service/3876193-1.html on August 11, 2008
- Sajdak,M. & Gerbarg, Z. B . Medical Management-Utilization Management “Signature Series” by Managed Care Resources, Inc. Retrieved from: http://www.mcres.com/mcrmm02.htm on August 11, 2008
- Yin,D. (1995). Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia 19104, USA. Retrieved from http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102215460.html on August 11, 2008
- Wills, J. (1994). Medical Director for Utilization and Review. Utilization Management Plan. Retrieved from http://216.239.59.104/search?q=cache:ypauYpNsjLQJ:hospitals.unm.edu/policies_and_procedures/docs/Preparedness%2520Plans/Utilization%2520Management%2520Plan.doc+components+and+processes+of+utilization+management&hl=en&ct=clnk&cd=2&gl=pk on August 11, 2008
