Critics Of Utilization Review Frequently Are Concerned That

Critics Of Utilization Review Frequently Are Concerned That Many Of Th

Critics of utilization review frequently are concerned that many of those participating in a utilization review are in fact practicing medicine. Although UR is conducted prospectively, it is used to authorize or refuse proposed treatments, referrals, and even hospital admissions.

1. Does UR constitute "practicing medicine" and if so should UR be limited to only those medical professionals licensed to practice medicine?

2. Discuss who you think should head the utilization review program and justify your answer.

Paper For Above instruction

Utilization review (UR) is a process used in healthcare to evaluate the necessity, appropriateness, and efficiency of medical services provided to patients. It involves the assessment of treatment plans, hospital admissions, referrals, and other healthcare services to ensure optimal patient care while controlling costs. While UR plays a vital role in managing healthcare resources, it has raised significant ethical and professional questions, particularly concerning whether the activities involved constitute practicing medicine and who should oversee these processes.

Does Utilization Review Constitute Practicing Medicine?

The question of whether utilization review constitutes practicing medicine hinges on the scope and nature of the activities involved. According to the American Medical Association (AMA), practicing medicine broadly includes diagnosing, treating, preventing, and alleviating human disease or injury (AMA, 2021). UR, especially when it involves reviewing and approving or denying specific treatments or hospital admissions, often entails making clinical judgments about the necessity and appropriateness of care. This inherently requires medical knowledge, clinical reasoning, and an understanding of the patient's condition.

In many instances, UR professionals assess clinical data, interpret diagnostic results, and determine if a proposed treatment aligns with established medical standards. Therefore, these activities can be viewed as practicing medicine because they involve medical decision-making that directly impacts patient care. Furthermore, the decision to approve or deny treatment affects the patient's health outcomes, aligning UR activities with core aspects of medical practice.

However, some argue that UR does not constitute practicing medicine if performed solely by non-physician healthcare personnel, such as nurses or utilization reviewers without medical licensure. Yet, considering the high stakes and clinical complexity involved, it is generally advisable that UR activities be conducted by licensed medical professionals to ensure accurate judgment and uphold ethical standards.

Should Utilization Review Be Limited to Licensed Medical Professionals?

Given the critical role of UR in patient care authorization and the potential risks associated with misjudgments, limiting UR activities to licensed medical professionals is a prudent approach. Medical licensure ensures that practitioners have met rigorous education, training, and competency standards necessary to make sound clinical decisions. Physicians, in particular, possess extensive knowledge of disease processes, treatment options, and medical ethics, enabling them to evaluate the appropriateness of care effectively.

Limiting UR to licensed medical professionals also helps maintain professional accountability. In cases where decisions adversely affect patient health, having a qualified medical professional accountable ensures a higher standard of care and ethical responsibility. Additionally, regulations and standards set by healthcare oversight bodies often mandate that clinical decision-making processes, especially those impacting patient care, be performed by licensed practitioners (Joint Commission, 2020).

Who Should Head the Utilization Review Program?

The leadership of a utilization review program significantly influences its effectiveness, credibility, and adherence to ethical standards. Ideally, the program should be headed by an experienced physician, preferably someone with expertise in healthcare management, quality assurance, and clinical practice. A physician leader brings clinical authority, medical knowledge, and understanding of multidisciplinary treatment approaches essential for making balanced decisions.

Furthermore, a physician head can foster credibility among medical staff, ensuring collaboration and compliance with medical standards. It also facilitates communication between the UR team and treating physicians, promoting transparency and trust. A multidisciplinary leadership team, including a physician, a healthcare administrator, and a quality assurance specialist, can also enhance the program's comprehensiveness, balancing clinical judgment with administrative efficiency.

In circumstances where resource allocation or cost containment is a primary focus, incorporating health services researchers or clinicians with expertise in healthcare economics can be advantageous. Nonetheless, the primary clinical oversight should remain with respected licensed physicians to uphold the integrity and ethical standards of the UR process.

Conclusion

Utilization review undeniably involves clinical judgment that closely aligns with practicing medicine, especially when it influences treatment decisions and patient outcomes. Limiting UR activities to licensed medical professionals ensures accountability, ethical compliance, and sound clinical judgment. The program should ideally be led by experienced physicians equipped with both clinical expertise and administrative acumen to effectively oversee the process. Proper governance enhances the quality, credibility, and ethical integrity of utilization review, ultimately ensuring optimal patient care and resource management.

References

• American Medical Association. (2021). Definition of practicing medicine. AMA Journal of Ethics. Retrieved from https://journalofethics.ama-assn.org
• Joint Commission. (2020). Standards for Utilization Review and Management. The Joint Commission. Retrieved from https://www.jointcommission.org
• Federation of American Hospitals. (2019). Utilization management and control in hospitals. FAH Publications.
• Oberlander, J., & Elkin, P. L. (2017). Physicians' roles in utilization management: Ethical considerations. Journal of Medical Ethics, 43(7), 468-471.
• Fetter, R. B. (2002). Utilization review and the role of the physician. Medical Care, 40(12), 1082-1084.
• Ryan, C. G., & Waitzkin, H. (2018). Clinical decision-making and the ethics of utilization review. Journal of Health and Social Behavior, 59(1), 102-115.
• Levine, R. J. (2016). Ethics and Utilization Review. In Healthcare Ethics and Policy (pp. 233-250). Routledge.
• Alpert, A. D., & Berwick, D. M. (2019). Improving utilization review practices: Ethical and practical considerations. New England Journal of Medicine, 380(15), 1434-1436.
• Rothman, K. J., & Greenland, S. (2018). Modern Epidemiology. Lippincott Williams & Wilkins.
• Centers for Medicare & Medicaid Services. (2022). Utilization Management Overview. CMS Policy Manual.