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Using the information in the required readings as well as some additional research in peer reviewed sources, complete your Case Assignment by answering the following: Compare and contrast utilization review and utilization management in health care. What are the similarities and the differences between each type of assessment? (Hint: One is generally a prospective process, and the other is generally a retrospective process). Explain the specific role of each method in providing value-based health care. Who benefits from the method—the health care system, the insurance company, and/or the patient? Articulate how individual case management is critical to a hospital’s long-term survival.

In what way does this practice protect your patients while keeping your doors open for business? What are the ethical pitfalls to be aware of in performing these types of quality reviews? What must health care managers be aware of in terms of ethical pitfalls and also potential unintended negative consequences? 5 pages required SOURCES: Baker, J. (2018). Improving quality of care through utilization management [Video file]. Retrieved from Carasso, S. (2017). Is that test necessary? The key to laboratory utilization management. The Journal of Medical Practice Management: MPM, 33 (3), . Retrieved from the Trident Online Library. Desai, S., Gruber, P. F., Eiting, E., Seabury, S. A., Mack, W. J., Voyageur, C., . . . Terp, S. (2017). The effect of utilization review on emergency department operations. Annals of Emergency Medicine, 70 (5), .e1. Retrieved from the Trident Online Library. El-Othmani, M. M., Sayeed, Z., Ramsey, J. A., Abaab, L., Little, B. E., & Saleh, K. J. (2019). The joint utilization management program: Implementation of a bundle payment model and comparison between year 1 and 2 results. The Journal of Arthroplasty, 34 (11), . Retrieved from the Trident Online Library. Parast, M. M., & Golmohammadi, D. (2019). Quality management in healthcare organizations: Empirical evidence from the Baldrige data. International Journal of Production Economics, 216, . Retrieved from the Trident Online Library. Suklar, S. (2018). Quality assurance system at primary level of healthcare. Izzivi Prihodnosti, 3 (1), 21-53. Retrieved from the Trident Online Library. Wakefield, E., Keller, H., Mianzo, H., Nagaraj, C. B., Tawde, S., & Ulm, E. (2018). Reduction of health care costs and improved appropriateness of incoming test orders: The impact of genetic counselor review in an academic genetic testing laboratory. Journal of Genetic Counseling, 27 (5), . Retrieved from the Trident Online Library.

Sample Paper For Above instruction

Introduction

In contemporary healthcare, the effective use of resources is paramount to ensure quality patient outcomes while maintaining financial sustainability. Utilization review (UR) and utilization management (UM) are two essential processes that serve to optimize healthcare services. This paper explores the distinctions and parallels between UR and UM, examining their roles within value-based care paradigms, identifying their beneficiaries, and emphasizing the importance of individual case management for hospital longevity. Additionally, it critically assesses ethical considerations integral to these processes, highlighting potential pitfalls and unintended consequences.

Definitions and Comparative Analysis of Utilization Review and Utilization Management

Utilization review (UR) is a systematic process used to evaluate the necessity, appropriateness, and efficiency of healthcare services, typically conducted retrospectively. It involves assessing clinical records after care delivery to determine if services rendered were essential and aligned with established criteria (Carasso, 2017). Conversely, utilization management (UM) functions proactively, aiming to influence the delivery of care before services are provided, often through pre-authorization or concurrent review. It emphasizes ongoing monitoring to prevent unnecessary or redundant services, thereby reducing costs and enhancing care quality (Baker, 2018).

The core difference lies in timing: UR is predominantly retrospective, scrutinizing existing healthcare activities, whereas UM is prospective, directing care delivery at the planning stage. Both processes rely on clinical guidelines, evidence-based protocols, and strict criteria to evaluate service appropriateness, ensuring the optimal allocation of limited resources (Desai et al., 2017).

Role in Delivering Value-Based Healthcare

Value-based healthcare prioritizes maximizing patient health outcomes relative to costs. UR and UM are critical tools in this context. UM aligns with value-based models by proactively managing care pathways, thus preventing overuse and unnecessary procedures, which are costly but offer minimal benefit (El-Othmani et al., 2019). It facilitates early intervention planning, coordinate multidisciplinary services, and streamline resource utilization, directly impacting patient satisfaction and outcomes.

UR complements UM by providing a retrospective assessment to identify patterns of overutilization or misuse that may have slipped through preventive strategies. It offers feedback for continuous quality improvement, ensuring that healthcare providers adhere to best practices and that patients receive necessary care without excess or deficiency (Parast & Golmohammadi, 2019).

Stakeholder Benefits

Healthcare systems benefit from optimized resource utilization, reduced unnecessary procedures, and improved operational efficiency. Insurance companies gain by controlling costs and reducing claims for unnecessary services, ultimately improving profitability. Patients stand to benefit through access to appropriate, necessary care, minimized exposure to invasive or unnecessary procedures, and improved health outcomes (Wakefield et al., 2018).

Importance of Individual Case Management in Hospital Survival

Individual case management is pivotal to a hospital’s sustainability by fostering personalized, coordinated care that addresses specific patient needs. Effective case management reduces hospital readmissions, enhances patient satisfaction, and improves health outcomes, all of which are vital metrics in today's reimbursement models (Suklar, 2018). It ensures resource-efficient care delivery, minimizes length of stay, and promotes interdisciplinary collaboration, forming the foundation of hospitals’ long-term viability.

Protection of Patients and Business Continuity

Implementing UR and UM practices safeguards patients by ensuring the appropriateness of procedures, preventing harm caused by unnecessary interventions, and promoting evidence-based treatment. Simultaneously, these processes help hospitals maintain financial health by curtailing wasteful spending, thereby securing their operational sustainability (El-Othmani et al., 2019). This dual benefit reinforces ethical practice—prioritizing patient safety while preserving the institution’s capacity to serve future patients.

Ethical Pitfalls and Considerations

Despite their benefits, UR and UM face ethical challenges. The potential for conflicts of interest exists if financial incentives influence decision-making, risking undertreatment or denial of necessary care. Overly rigid adherence to protocols may compromise individual patient needs. Healthcare managers must be vigilant against biases, ensure transparency, and uphold clinical judgment integrity (Baker, 2018).

Unintended negative consequences include delaying critical care, increasing administrative burden, and fostering distrust between providers and patients. Ethical practice requires balancing cost-containment with compassion, staying aligned with core principles of beneficence and non-maleficence (Suklar, 2018).

Conclusion

Utilization review and utilization management are integral to modern healthcare, offering mechanisms to optimize resource use, enhance patient outcomes, and ensure a financially sustainable system. Their prospective and retrospective natures complement each other, driving continuous quality improvement. Recognizing and addressing ethical pitfalls is essential to harness these practices' full benefits, ultimately safeguarding both patient welfare and institutional viability.

References

• Baker, J. (2018). Improving quality of care through utilization management [Video file].
• Carasso, S. (2017). Is that test necessary? The key to laboratory utilization management. The Journal of Medical Practice Management: MPM, 33 (3).
• Desai, S., Gruber, P. F., Eiting, E., Seabury, S. A., Mack, W. J., Voyageur, C., . . . Terp, S. (2017). The effect of utilization review on emergency department operations. Annals of Emergency Medicine, 70 (5), .e1.
• El-Othmani, M. M., Sayeed, Z., Ramsey, J. A., Abaab, L., Little, B. E., & Saleh, K. J. (2019). The joint utilization management program: Implementation of a bundle payment model and comparison between year 1 and 2 results. The Journal of Arthroplasty, 34 (11).
• Parast, M. M., & Golmohammadi, D. (2019). Quality management in healthcare organizations: Empirical evidence from the Baldrige data. International Journal of Production Economics, 216.
• Suklar, S. (2018). Quality assurance system at primary level of healthcare. Izzivi Prihodnosti, 3 (1), 21-53.
• Wakefield, E., Keller, H., Mianzo, H., Nagaraj, C. B., Tawde, S., & Ulm, E. (2018). Reduction of health care costs and improved appropriateness of incoming test orders: The impact of genetic counselor review in an academic genetic testing laboratory. Journal of Genetic Counseling, 27 (5).