Utilization Review And Quality Management In Health Care

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…
One aspect of perspective utilization involves demand management, which empowers the patient to not misappropriate the use of healthcare services, by providing necessary tools to educate the patient on when it is appropriate to seek emergency care (White, 1998). Moreover, it gives the patient tools to improve their health, thus the likelihood of the patient using health services is lowered (White, 1998). Consequently, demand management in the end saves the managed care organizations and the enrollee (patient) money by not misappropriating health services. For instance, Blue Cross Shield offers there enrollee’s a discount for gym memberships and healthy foods, thus causing enrollee to become healthier and not needing as many health services. Additionally, Total Health Care has a 24-hour nurse line so that the enrollee’s may call to see if emergency care is …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

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