Utilization In Healthcare

1077 Words 4 Pages
By the year, 2024 United States Government and local governments will have spent at least half of its national budget on healthcare according to a recent study issued by the federal government (Luhby, 2015, para. 9), which is in part due to the Affordable Care Act. In addition, the government has estimated by 2024 that the cost of healthcare for each person will rise at least 5.8% per year (Luhby, 2015, para. 4), which in some way is due to the rising age of the American population. Therefore, utilization review and quality management become more critical as the cost of healthcare continues to rise. Utilization review and quality management go hand in hand, but they are distinctly different in managing the costs of healthcare. Utilization …show more content…
162). The general practitioner makes sure the patient does not unnecessarily see a specialist for their condition by using the referral management system (Kongstvedt, 2016, p. 162). In fact, the managed care organization will even send periodic reports to the general practitioner about referral rates and costs, thus keeping the general practitioner aware of the appropriate amount of capital being spent (Kongstvedt, 2016, p. 162). In essence, referral management keeps the physician from overspending the health management organizations money while at the same time protecting the physician’s money. Consequently, the patient may feel that their health is truly not being taken into consideration. As an example, Priority Health requires the patient to see their general practitioner when wanting to see a specialist for their medical condition, such as knee …show more content…
164). The utilization management nurse will conduct their research and compare them to the medically evidence-based guidelines, which helps to determine if the patient still needs to be in the medical facility (Kongstvedt, 2016, p. 164). Additionally, the managed care organization will send their own utilization management nurse to ensure proper guidelines are being used by the medical (Kongstvedt, 2016, p. 164), consequently saving the medical facility and their organization money. Furthermore, discharge planning is considered part of current utilization management because it aids in the medical facility meeting avoidable readmissions by Medicare patients (Kongstvedt, 2016, p. 165). Therefore, in the end by the facility using concurrent utilization management and discharge planning it allows them to receive possibly more profit. In fact, this can be used while treating the patient for outpatient care, such as physical therapy. The Managed Care Organization will only allow six visits, and then require position to send the medical diagnosis codes and notes to see if the patient still should be seen. Subsequently, the patient sometimes has to be put on hold until the managed care organization approves of continued care. Once again, the stalling of medical care causes

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