MHA628 Week 3 Discussion
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University Of Arizona *
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628
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Industrial Engineering
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Nov 24, 2024
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Utilization Management [WLOs: 1, 2, 3] [CLOs: 1, 4, 5, 6]
Prior to beginning work on this discussion forum, review the following:
Chapter 5: Utilization Management, Quality Management, and Accreditation
Variation in Practice for Preoperative Antibiotic Prophylaxis: A Survey From An Academic Tertiary Referral Center in the United States Links to an external site.
What We Talk About When We Talk About Care Management Links to an external site.
Best Practices in Utilization Management Links to an external site.
Medication Utilization. . .The Great Multiplier! Links to an external site.
Getting to Know the PerformRx Drug Therapy Management Program
Links to an external site.
Utilization management helps health care organizations control costs and improve quality. The principal objective of utilization management is the reduction of practice variations by establishing parameters for cost-effective use of health care resources.
For this discussion, you are taking on the role of the director of utilization management at Mount St. Clare Medical Center. Some practice variations have been observed among health care providers at your medical center. Your CEO asks you to conduct training for your health care providers.
In your initial post,
Differentiate three basic components of utilization management as depicted in Figure 5.1 in Chapter 5 of your textbook.
Explain the importance of drug utilization review and step therapy.
Distinguish between disease management (DM) and case management.
Examine a successful DM program (e.g., Aetna Health Connections disease management program) from real-life provided by an employer, hospital, health insurer, or other entity. Be sure to address its accreditation or certification status, if any, and its impacts on health care quality and cost.
Your initial post should be at least 500 words. Support your response with a minimum of two scholarly sources published in the last 5 years. Your sources must be formatted according to APA Style
Links to an external site.
as outlined in the Writing Center. The Scholarly, Peer-Reviewed, and Other Credible Sources
Links to an external site.
table offers additional guidance on appropriate source types.
Differentiate three basic components of utilization management as depicted in Figure 5.1 in Chapter 5 of your textbook.
Total membership or total enrollees is the number of members or enrollees enrolled into a health insurance plan. The total number of outpatient procedures in the month is the number of patients who are enrolled in a specific health insurance plan that has underdone outpatient procedures in each month. The average cost per outpatient procedure in a month is the average cost per outpatient procedure paid by the product or health insurance plan in a month. According to our textbook (Kongstvedt, P. R., 2020), procedure costs are widely ranged in cost, even for the same procedures, therefore for simplification, healthcare organizations would use the average cost to estimate the total gross cost of the outpatient procedure in a given month and calculate cost on a per member per month (PMPM) basis. Explain the importance of drug utilization review and step therapy.
Drug utilization review (DUR) is an ongoing, systematic quality-improvement activity and strategies for managing the volume and pattern of prescriptions (Kongstvedt, P. R., 2020), A Drug utilization review strategy constructs prescription profiles to ensure the effective and appropriate use of medicines. The constriction provides information to physicians to be able to compare their prescribing patterns with those of their peers. Drug utilization review considers a formulary system management technique comprised of a comprehensive review of a patient's health and medication history before, during, and after dispensing medicines to optimize patient outcomes (Carver et al, 2023). The extensive and comprehensive review provides quality assurance, prescriber feedback, corrective action, and additional evaluations performed by pharmacists as an ongoing systemic effort to improve the quality of patient care, reduce inappropriate pharmaceutical expenditures, and thus reduce overall healthcare costs.
A step strategy is a form of drug utilization review that assesses precertification for costly drugs following the assessment of patients who demonstrate experiencing side effects or inadequate response to treatment with less costly alternative drugs. The assessment, if deemed sound and valid will be considered and authorized for the coverage of costlier treatment.
Distinguish between disease management (DM) and case management (CM).
Case management is a healthcare process in which medical professionals support a patient by developing a plan that coordinates and integrates care delivery services to optimize healthcare
goals and outcomes. Case management is composed of a wide array of services, supports, and benefits that patients have access to, including healthy lifestyle programs, recreational activities, and social enrichment programs within a benefit plan. The cost management program is common and is included in most payer-benefit health plans (Kongstvedt, P. R., 2020). Traditional case management emphasizes individual patients, early identification of people with acute catastrophic conditions with known high costs or diagnoses known to lead to high costs in the near term, and value relies heavily on price negotiations and benefit flexing, and often community resources as well. Disease Management has similarities to case management. However, disease management focuses on selected medical conditions for the patient to manage the course of chronic diseases and to avoid hospitalizations. Disease management programs involve coordinated interventions for patient populations in which improvement in self-care has been shown to have significant effects (Goodridge et al., 2019). Disease management emphasizes an individual in a population with a chronic illness, early identification of all people with targeted chronic diseases whether mild, moderate, or severe, and value stems from member and provider behavior change those results in improved health status (Kongstvedt, P.R., 2020). Disease Management Programs have been successful in empowering many individuals living with chronic illnesses, such as chronic obstructive pulmonary disease (COPD), to assume greater influence over their health and achieve improved health outcomes. According to our textbook (Kongstvedt, P. R. (2020), disease management programs utilize computer programs to analyze medical and drug benefit claims to diagnose, identify, and determine the level of interventions that would be most appropriate for the patient.
Examine a successful DM program (e.g., Aetna Health Connections disease management program) from real life provided by an employer, hospital, health insurer, or other entity. Be sure to address its accreditation or certification status, if any, and its impacts on healthcare quality and cost.
BlueShield of California's disease management program is designed to support members in managing their chronic conditions, improving quality of life, and reducing the cost of healthcare. BlueShield of California’s approach to disease management uses best practice treatment guidelines that allow members to actively take on the role of managing their conditions (Blueshieldca.com, n.d.). The impact on healthcare quality and cost is strongly driven by the leveraging of telehealth and health information technology (HIT). BlueShield of California disease management by leveraging telehealth as part of the “whole person” approach integrating digital platforms such as Nursehelp 24/7, case management program, Caretip clinical messaging, and BlueShield of California WellBeing Assessment application. The following integrated suite of applications and programs embedded in their disease management program shares a single technology platform that allows visibility and cross-
program coordination among clinicians and increases provider-patient communication to deliver a streamless experience for the patient/member.
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