Utilization management (UM) in the health care system is the assessment of medical efficiency, essential and suitability of the use of the healthcare procedures, services and facilities that are beneath the stipulation of applicable health benefits plan. Utilization management has been applied in the health care system in different ways to help people attain the medical services they require at an affordable cost (Kim et al., 2011). Utilization management in the healthcare can be done by influencing the decision-making of the patient`s care by evaluating each case and its appropriateness before it is provided to the patient. It helps in the minimization of the use of the hospital resources through some stipulated guidelines. Its use in the medical institution has helped in saving money for the managed care organizations and more investment done on the utilization management. The rise in the medical cost and the increased number of patients require a strategic plan that can help ensure that the patients get the quality care they require at a minimized cost.
There is demand management which is an application of the UM and an implementation to help in minimizing the misuse of the resources aims at the approaches that ensure that the necessary and the effective care is given to the patients (Kongstvedt, 2012). Introduction of the nurse's advice line is a form of demand management in the health care plan. The plan includes nurses that avail themselves to answer some of the questions for the patients or clients throughout the day and week when they need it. That kind of service has been adopted in other places like Medicaid to create efficiency. The nurse line has also helped reduce the number of people crowding the hospital for problems they can solve without come to the hospital.
Various types of utilization management include prospective review, concurrent review, and retrospective review. The prospective review is conducted before the care services are provided to the patient to reduce or get rid of the needless services. The prospective review can have an expected impact on the already decided by the providers. It can result in limiting the recommended care or deny its authorization. Concurrent review is done during the treatment period or in the incident of care. Interference can be done at any time in intervals during the period of the treatment that may include case management activities like discharge planning, care coordination or transitioning. The process may have a restriction impact on an existing period of care. Retrospective review is done after the care services have been rendered (Kim et al., 2011). It is done to investigate whether the services were given by the setting, procedure, and timing as per the required criterion. These reviews can always result in denial of a claim because they relate to payment issues. The providers in some of these cases usually suffer the financial risk due to the display of denial.
Nashville is known as the City Hospital as well as Nashville General Hospital. It was the first medical facility with full services in Nashville. It began small with few beds one physician and seven nurses, but it grew larger and now can hold 150 beds. The hospital today is a community hospital and academically affiliated. The city provides the hospital with financial support which in return the hospital grants medical care to the city`s most vulnerable individuals who cannot afford to pay for their health care. The rest of its finances are obtained from customers with insurance. The hospital mainly deals with the less fortunate people from the community who usually has medical, economic and social challenges. They work with their patients to ensure that they get a long-term solution for their medical problem (Nashville, 2017). They help them obtain a primary care physician and also create a patient-centered medical home. They empower as well as educate the patients on the significance of making healthy choices that are good for them and ways to meet their other challenging needs. The hospital sponsors and participates in the healthcare events. Charitable organizations such as the Friends in General also provide the hospital with resources to support the community services. The Mammogram in May is a program offered by the hospital that helps the vulnerable women in the community to have free screening mammograms if they have not had one in the last year.
Nashville General Hospital can be said to apply utilization management. The hospital focuses on helping the community member that cannot afford their healthcare. Apart from giving them the care, they also help them acquire physician and long-term healthcare solution. The hospital before offering their services ensures that the person cannot afford to pay for their medical services before they are treated. The Mammogram in May program helps the women who would never have thought of getting that screening if it was not offered for free. Educating and empowering the patient to make good health choices is a way of prevention of some medical conditions and problems that may arise. These programs can all be placed on utilization management done by the hospital as they use their resources given by the city and the charity to help the community. The hospital has adhered to the recognized utilization standard when rendering their services to the community when giving care to the vulnerable people of the community. The review done have helped in improving the state of health of the community and the quality of service they offer to their customers.
The Nashville hospital depends mostly on its staff to create a good relationship with their clients. It uses the available resources to ensure they provide quality service, which is evident by the number of the contracting staff they use that is less than 2% (Nashville, 2017). Other than the financial support from the city, the hospital obtains its resources that they use to support community services from its charity arm the Friends in General. The hospital has managed well to use their available resources that they acquire to support the community and have managed to create a good medical care for many people. The hospital should ensure that they have a follow-up on all the people they have given ways of obtaining the medical care and ways to solve their other challenges so that they do not give up and end in their original state. The hospital should try to look for support from other organizations to support their programs since they mainly help the vulnerable people who cannot afford to pay their medical bill. The hospital can be said to have a good utilization management depending on the number of the vulnerable patients they have given quality service to base on the resources they have.
Adirim, T., Meade, K., & Mistry, K. (2016). A New Era in Quality Measurement: The Development and Application of Quality Measures. Pediatrics, e20163442.
Kongstvedt, P. R. (2012). Essentials of managed health care. Jones & Bartlett Publishers.
Kim, J. Y., Dzik, W. H., Dighe, A. S., & Lewandrowski, K. B. (2011). Utilization management in a large urban academic medical center: a 10-year experience. American journal of clinical pathology, 135(1), 108-118.
Mathias, P. C., Conta, J. H., Konnick, E. Q., Sternen, D. L., Stasi, S. M., Cole, B. L., . . . Dickerson, J. A. (2016). Preventing genetic testing order errors with a laboratory utilization management program. American Journal of Clinical Pathology, 146(2), 221-226. doi:10.1093/ajcp/aqw105Nashville General Hospital. (2017). Retrieved from http://www.tncpe.org/awards/apply/application-packets/1612-application-and-org-profile.pdf
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