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REVIEWER KNOWLEDGE: This is a key component of a highly effective utilization management program. The knowledge of the reviewer is highly crucial to the effectivesness of the UM program. The reviewer needs to be knowledgeable in all aspects of the UM program especially the clinical care and service delivery. In depth knowledge is an essential criteria for making of wise and informed decisions . Reviewing transfers, reviewing carve outs and appealing denials require a good knowledge of the reviewer to make the the appropriate decisions on this matter.
REVIEWER COURAGE: The reviewer courage to make difficult decisions also affect the effectiveness of a UM program. “The concept of efficient utilization practices commonly conflicts with physicians’ and nurses’ role to meet the total needs of patients and family”. For a UM program to be successful, the reviewer should be courageous enough to insist on the implementation of the UM guidelines and protocol.
SYSTEM INTEGRITY: The integrity of the system should not be compromised. This responsibility is vested on accreditation agencies like National committee on quality assurance (NCQA) , Joint Commission on Accreditation of Healthcare Organization (JCAHO) and the Utilization Review Accreditation Commission (URAC). To ensure the integrity of the delivery system, periodic recertification of providers is conducted.
RIGORS OF STANDARDS: Standard practices are usually set for the clinical care and service delivery. Adhering to the set standards is essential for the effectiveness of a UM program. Documenting standard practices help to clarify acceptable practices. Standard practices should be shared with the necessary agencies like the commercial payers, hospitals and the accreditation agencies. This helps to prevent conflicts between these bodies. “For example, standard practice may require all commercial payers to notify the hospital of their denials by 2 pm of the denial day. This time frame allows the utilization management staff to obtain additional information for disputed decisions or issued a timely denial letter to the patient who no longer require an acute level of care. It also eliminate retrospective denial.
PHYSICIAN HOSTILITY: “The concept of efficient utilization practices commonly conflicts with physicians’ and nurses’ traditional role to meet the total needs of patients and family.” Thus physicians are naturally hostile to UM program. Curbing this natural hostility is key to the effectiveness of the UM program. This is because physicians are the essential provider of the clinical care.
SUPPORTIVE BENEFIT PLAN DESIGN: This is also a key component that determine the effectiveness of the UM program The supportive benefit plan of an effective UM program should be broad covering a wide range of services. A supportive benefit plan design should provide emergency coverage, specialty care, medication for chronic conditions and elimination of cost sharing.
Quality studies, a key quality management process, are routinely conducted on clinical and service issues. Quality studies help to provide data for service improvement.The conduct of quality studies is also a requirement for accreditation by various accreditation agencies. Accreditation helps to boost the rating of a health management organization(HMO). Thus quality studies should be a high priority for an MCO, if it want to remain in business.
The following quality studies can be conducted by an HMO:
(a). Analysis of members compliants.
(b). Clinical studies of re-admission to the hospitals within four weeks.
(c). Prescription case management programs.
(d). Prescriber feedback programs.
(e). Evaluation of physicians performance.
ANALYSIS OF MEMBERS COMPLIANTS: The consumers of an HMO service are the the greatest source of information regarding the quality of the service. They provide valuable information to the HMO about the clinical care and service issues. Analysis of members compliants usually provide valuable data about the quality and shortcoming of the HMO service . These data direct the HMO on the areas that should be improved on.
CLINICAL STUDIES OF THE RE-ADMISSIONS TO THE HOSPITAL WITHIN FOUR WEEKS: This gives a good indication of the quality of the clinical care provided. If the number of patients re-admission is high, it indicates poor quality of clinical care. Evaluation of the performance of the institutions or physicians should be done to decide the next step to be taken. While a low rate of re-admissions signifies a high quality of service.
PRESCRIPTION CASE MANAGEMENT PROGRAMS: These programs help to monitor and ensure appropriate medication usage. A team of physicians or pharmacist usually review the cases and recommendation to improve the care. This has a positive effect on the quality of the clinical care provided.
PRESCRIBER FEEDBACK PROGRAMS: These programs review pharmacy claims data and provide doctor with feedback about their patterns and recommended practices. These programs help to improve the efficiency of the physicians . This leads to improvement in the quality of clinical service provided.
PERFORMANCE EVALUATION OF PHYSICIANS: Performance eveluation should be conducted on each physician. This evaluation should be used in credentialing each physician. This will make each physician to give their best as their reputation is based on the quality of service provided. This might go a long way to improve the quality of the clinical service.
CHARACTERISTICS OF A QUALITY MANAGEMENT SYSTEM
Many managed care organizations(MCOs) find it hard to convince their prospective clients that they place a high premium on the quality of service given to their customers. Convincing clients that clinical care is place higher that the clinical cost is a herculean task for many MCOs. This is because of the popular notion about MCOs shylock’s profit mentality. Jan greene in a recently published article questions whether or not managed care has lost its soul. “In that article, Greene noted that managed care was once dominated by not-for-profit organization with a social mission. Now most managed care is primarily governed by their profit motive only to the detriment of the quality of service given to their clients”. Also, recent trends which shift the financial risk to clients through capitation and other systems that concomitantly give clinical care providers financial incentives to withhold necessary care has led to increased negative perception of MCOs”. With this negative perception towards MCOs, selecting a quality management system should be the top priority of any MCO. A quality management system will enable an MCO to win the confidence of its clients.
“A quality management system incorporate both reactive (quality assurance) and proactive (quality improvement) systems and even go a step further to direct a management philosophy”.It is safe to say that almost all MCOs employ a reactive approach to the quality of service provided. Most have adopted a proactive approach, and a selected few have fully incorporated the principles of quality management. “In the future, the basic standard in MCOs will be quality improvement rather quality assurance”. Thus incorporating quality management system will give your firm a competitive edge over others.
The following are the essential characteristics of a quality management system:
CLEAR MISSION AND GOALS: Creating a clear mission and specific goals is one of the characteristics of a quality management system. A mission statement should be created.The mission and goals should be clear and specific. This will make them easily understandable by the staff members. Thus they can align their actions and behavior towards achieving the goals and mission of the quality management system.
ACTIVE LEADERSHIP: Active medical and administrative leadership is a key characteristics of a quality management system. Active leadership in the various departments will ensure that firm’s quality policy will be pass down to the staff members. This will ensure that the quality standards and policies are strictly adhered to.
DEFINED STRUCTURE AND ACCOUNTABILITY: This creates a division of labour and assign responsibilities to each division. This also minimizes clash of interest which is detrimental to the success of a quality management system. Accountability for quality needs to come from the top. “ While primary responsibilty should be held by the Board of Directors, it is often delegated to the medical and administrative leaders for day-to-day operations. This does not negate responsibility of the board, but rather forces a direct line of communication between those that do everyday work and those that are accountable for the final outcome”.
CO-ORDINATED ACTIVITIES: Apart from creating a defined structure and assigning responsibilities, it is very important to co-ordinate the activities of the various structures. This is essential to ensure the smooth operation of the system.
EFFECTIVE PLANNING: Planning is an essential part of a quality management system. Roberta .L. Carefoote has said it all in her article “Medical Care and Quality Management” . She noted that that in a quality management system, there are three important planning processes- the development of an annual description of quality management , an annual plan that outline activities critical to achieving the objectives set out in the management description and a process that allows the MCO to evaluate its performance relative to the plan.
COMPREHENSIVE SCOPE OF SERVICES: A scope of sevices usually include the clinical care and service delivery offered. The clinical care is the various clinical services that is offered to clients. It should be broad and include several benefits like emergency care and specialty care. The scope of services should be reviewed regularly and improvements should be made from time to time.
FOCUS ON IMPROVEMENT: There is always a room for improvement. Quality studies should be conducted regularly to assess the quality of the clinical care and service delivery. Shortcomings discovered should be worked on and improved. This should be done regularly. The focus of the quality management system should always be on improvement .
DATA DRIVEN DECISION MAKING: Clinical care and service delivery data should be collected regularly and analyzed. This can gotten from quality studies such as analysis of clients’ compliants and prescription case managements programs. Decisions should be made based on the collected data. This is essential to the improvement on the quality of services offered.
SOUND POLICIES AND PROCEDURES: Sound policies and procedures should formulated and implemented. This policies and procedures should be made with the highest attainable standard in mind. Proper documentation and communication of policies and procedures should be done regularly. Infact, a quality manual should be produced and updated regularly.
ADEQUATE RESOURCES: Adequate resources include skilled staff to implement the quality management plan, data analysis tools and information system. These play a great role in determining the outcome of the quality management system. Acquiring these resources should therefore be a high priority.
Adopting quality management system will make the name of your organization be synonymous with quality care and service delivery. This will set it out from the crowd of other MCOs, putting it in a class of its own.