Utilization Review And Quality Management In Health Care
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