With the consistently rising costs of health care services, utilization management and utilization review are routinely used in the vast majority of current health care settings. How are they evolving over time, and what is involved in these processes? What do health care managers need to be aware of as the processes play out?
In the absence of sweeping policy change (or the complete restructuring of the United States health care system), utilization management and utilization review are much more moderate processes to attempt to preserve the quality of care provided while controlling overall health care expenditures. Letâ€™s learn a bit about each of these processes, and how they are implemented in our current health care environment.
Using the information in the required readings as well as some additional research in peer
reviewed sources, complete your Case Assignment by answering the following:
- Compare and contrast utilization review and utilization management in health care. What are the similarities and the differences between each type of assessment? (Hint: One is generally a prospective process, and the other is generally a retrospective process).
- Explain the specific role of each method in providing value-based health care. Who benefits from the methodâ€”the health care system, the insurance company, and/or the patient?
- Articulate how individual case management is critical to a hospitalâ€™s long-term survival. In what way does this practice protect your patients while keeping your doors open for business?
- What are the ethical pitfalls to be aware of in performing these types of quality reviews? What must health care managers be aware of in terms of ethical pitfalls and also potential unintended negative consequences?
- Conduct additional research to gather sufficient information to support your analysis.
- Provide a response of 3-5 pages, not including title page and references.
- As we have multiple required items to be addressed herein, please use subheadings to show where youâ€™re responding to each required item and to ensure that none are omitted.
- Support your paper with peer-reviewed articles and reliable sources. Use at least three references, and a minimum of two of these from peer-reviewed sources. For additional information on how to recognize peer-reviewed journals, see:
Angelo State University Library. (n.d.). Library Guides: How to recognize peer-reviewed (refereed) journals. Retrieved from https://www.angelo.edu/services/library/handouts/peerrev.php
and for evaluating internet sources:
Georgetown University Library. (n.d.). Evaluating internet resources. Retrieved from
- You may use the following source to assist in your formatting your assignment:
Purdue Online Writing Lab. (n.d.). General APA guidelines. Retrieved from https://owl.english.purdue.edu/owl/resource/560/01/.
- Paraphrase all source information into your own words carefully, and use in-text citations.
Module 2 – Background
Utilization Management, Utilization Review, and Case Management Essentials
Baker, J. (2018). Improving quality of care through utilization management [Video file]. Retrieved from https://youtu.be/g-T-YeP53nY
Carasso, S. (2017). Is that test necessary? The key to laboratory utilization management.
The Journal of Medical Practice Management: MPM, 33(3), 160-164. Retrieved from the
Trident Online Library.
Desai, S., Gruber, P. F., Eiting, E., Seabury, S. A., Mack, W. J., Voyageur, C., . . . Terp, S. (2017). The effect of utilization review on emergency department operations. Annals of Emergency Medicine, 70(5), 623-631.e1. Retrieved from the Trident Online Library.
El-Othmani, M. M., Sayeed, Z., Ramsey, J. A., Abaab, L., Little, B. E., & Saleh, K. J. (2019).
The joint utilization management program: Implementation of a bundle payment model and
comparison between year 1 and 2 results. The Journal of Arthroplasty, 34(11), 2532-2537.
Retrieved from the Trident Online Library.
Parast, M. M., & Golmohammadi, D. (2019). Quality management in healthcare
organizations: Empirical evidence from the Baldrige data. International Journal of Production
Economics, 216, 133-144. Retrieved from the Trident Online Library.
Suklar, S. (2018). Quality assurance system at primary level of healthcare. Izzivi Prihodnosti, 3(1), 21-53. Retrieved from the Trident Online Library.
Wakefield, E., Keller, H., Mianzo, H., Nagaraj, C. B., Tawde, S., & Ulm, E. (2018). Reduction
of health care costs and improved appropriateness of incoming test orders: The impact of
genetic counselor review in an academic genetic testing laboratory. Journal of Genetic
Counseling, 27(5), 1067-1073. Retrieved from the Trident Online Library.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Available at https://www.ncbi.nlm.nih.gov/books/NBK222274/
(Use this link for free full text .pdf download).