Stream-Line Your Utilization Management Process

UM is a combination of techniques used by or on behalf of purchasers of health benefits to manage health care costs by prompting patient care decision-making over case-by-case assessments of the suitability of care. The rationale for UM rests on three underlying assumptions:

  • In a predominantly fee-for-service payment system there is considerable unnecessary and inefficient care provided to patients.
  • Unnecessary care can be controlled, saving substantial amounts of money and improving the quality of care.
  • The cost of operating UM systems is small compared with the savings.

A large majority of Americans are now registered in privately or publicly sponsored health plans that use utilization management (UM) programs as a primary cost-controlling strategy. Out of the total number, includes 90 percent of privately insured employees as well as Medicare and Medicaid participants. If you consider that until the mid-80’s only a handful of employees were enrolled in these programs, the growth of UM has been remarkable.

Now that UM programs are well-known, it is the suitable time to evaluate their impact and to take steps for their future role in the health care delivery system. There is extensive research on UM (mainly for inpatient care), and a small but emerging body of scientifically tough analytic work evaluating its effect on utilization, costs, and quality.

So the question remains – will externally run public and private UM programs continue? If yes, what changes are likely in UM operations over the next 5 to 10 years? UM programs utilized in health maintenance organizations (HMOs), preferred provider organizations (PPOs), and other network-based managed care plans are exempted because their effects are confused by the other intrinsic cost-containment features.

Extensive research into this area suggests that perhaps 10 to 30 percent of diagnostic tests, procedures, and hospital admissions are meaningless. Whether or not UM can control unnecessary care and do it efficiently is addressed in this 60 minute webinar. Two general features of effectiveness are deliberated: Medical care utilization and costs at the program and system levels and the quality of care.

For a complete analysis of the Utilization Management Process, join expert speaker Toni G. Cesta, Ph.D., RN, FAAN in an online conference titled – Utilization Management: What Does it Really Mean for Today’s Case Manager”. This session will review the role of utilization management as it applies to today’s contemporary case management models. This will include best-practice suggestions for your practice with tips and strategies for stream-lining the process and making it as efficient as possible.

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