Managed Care




Utilization management refers to the non-price mechanisms used tolimit the impact of moral hazards in medical care (Buttigieg,Rathert, &amp von Eiff, 2015). It could also cover the evaluationprocedures used to measure the efficiency, appropriateness, andnecessity of health care facilities and services. In many instances,utilization management is usually ensured under a particular benefitsplan (Buttigieg et al., 2015). Consequently, it provides the highestquality of health care in the most applicable setting (Healey &ampEvans, 2015). It also ensures that the most qualified practitionersand providers attend to the patients` pertinent needs.

Nevertheless, abandoning the efforts of utilization management hasvarious consequences. With regards to claims experience, foregoingutilization management would increase the number and value of claims.As mentioned, utilization programs seek to guarantee theappropriateness and cost-effectiveness of health care plans(Buttigieg et al., 2015). They also value the importance of improvinghealth care services. Therefore, outpatient resources are utilizedmore frequently than inpatient sources. The increased use ofhome-based care reduces the costs of health care. Health insuranceplans are ordinarily taken to cater for inpatient hospitaladmissions. In this respect, discontinuing the efforts of utilizationmanagement would increase the number of claims since cost-effectivestrategies are eradicated (Guttner &amp Soyez, 2015). The value ofclaims will also increase as treatments become more expensive.

Besides, abandoning the practice of utilization management would havedetrimental effects on enrollment. For example, fewer people willafford health cover. In situations where the cost of health carerises, insurance companies respond by increasing the level ofpremiums (Guttner &amp Soyez, 2015). The occurrence of pandemics andother perilous outbreaks causes widespread panic in health caresystems. Pestilences would also destabilize medical procedures sinceprevious cures would be rendered redundant (Guttner &amp Soyez,2015). Under such circumstances, utilization management would work tostreamline operations and reduce the strain on resources. However,the lack of utilization programs would force patients to spend theavailable resources on immediate forms of treatment (Buttigieg etal., 2015). Consequently, the number of enrolments into establishedhealth care plans would reduce.

Various criteria would have to be used to determine whether autilization management program should be implemented. Staff membershave identified some factors that hinder their application ofutilization management. For example, there seems to be a lack ofprocesses that can be used during follow-up (Guttner &amp Soyez,2015). Such a barrier occurs mostly during adverse medical events.Also, clinical floor personnel offer little support during qualityimprovement. Some staffers are discouraged by the lack ofinstitutional recognition and support from the managers of healthcare facilities. In some cases, leaders show little concern for theimprovement of quality (Guttner &amp Soyez, 2015). Furthermore, someorganizational structures frustrate communication among variousdepartments. Therefore, the continuation of a utilization program canbe evaluated using the gravity of existing barriers.

Utilization management requires accurate and efficient collection andclassification of data (Buttigieg et al., 2015). Aggregation ofinformation also requires enough tools and human resources. Tools areusually classified in terms of systems and information technologywhile human resources are graded with regards to the time andmanpower required to accomplish essential tasks (Buttigieg et al.,2015). Consequently, the implementation of a utilization programdepends on the number of human resources and tools.

In addition, evaluating the necessity of implementing utilizationmanagement considers several opportunities. For example, staffmembers can be trained to become adept at collecting operationalvariance information (Guttner &amp Soyez, 2015). Gathering othernonclinical data also helps to pinpoint delays and omissions inhealth care that may signify problems in quality. The workers canalso be included in action plans created for the sake of qualityimprovement (Guttner &amp Soyez, 2015). Such a step recognizes theunique role played by utilization management employees. Moreover, theinformation collected by staff members is ordinarily significantduring the determination of quality standards. Regular discussionsshould be held among staff members to highlight opportunities forimprovements in quality and service guidelines (Guttner &amp Soyez,2015). It is critical to adopt strategies that unite the functions ofvarious departments.

Granted, procedures for utilization management seldom focus on theoccurrence of care delays. Rather, they ensure that admitted patientsenjoy the basic tenets of medical care (Guttner &amp Soyez, 2015).Also, some utilization managers avoid interfering with blatantomissions while patient care is ongoing. Such negligence can beattributed to the fact that utilization management fails to rewarddiligence and reliability. Therefore, evaluating the continuation ofutilization programs requires that certain modifications are made inthe expectations placed on staff members (Guttner &amp Soyez, 2015).Appropriate tools must also be provided to facilitate effectivenessin their duties.

Moreover, it is crucial to determine whether utilization managementworkers fulfill their duties. For example, professionals are expectedto discuss the patients’ length of stay upon admission into ahospital (Healey &amp Evans, 2015). The workers must also conductperiodic evaluations of the readiness of patients to be discharged. Aprobable release date must also be determined for each patient. Staffmembers take care to avoid overusing or underutilizing the availablemedical resources (Healey &amp Evans, 2015). In some cases, it mayhelp to organize the transition to other levels of health care.Nevertheless, the latter approach is mostly used for comatose andchronically-ill patients (Healey &amp Evans, 2015). Properdischarging of duties at a health care facility would renderutilization management as worthy of continued support.

Furthermore, quality evaluations can be used to determine thecontinued use of utilization management. In this regard, it helps toexamine the levels of satisfaction expressed by employers, patients,and providers. In many cases, health care practitioners harborreservations against utilization management programs (Buttigieg etal., 2015). For example, many providers are forced to justify theirdecisions with regards to patient admissions and length of stay. Inaddition, complicated procedures are used to liaise with utilizationmanagement companies before embarking on patient care (Buttigieg etal., 2015). The review staff members are also unpleasant since theyhave little knowledge of the patient and yet try to dictate theappropriate means of treatment (Buttigieg et al., 2015). Besides,physicians are burdened with operating expenses and multiple sets ofclinical rules imposed by utilization management programs (Buttigieget al., 2015). Consequently, evaluating quality standards can help toidentify whether a program is fit to proceed.

Ultimately, all utilization management programs should be assessedusing three major assumptions. Firstly, utilization systems presumethat the costs of operation dwarf the amount of possible savings(Buttigieg et al., 2015). Secondly, the programs assume thatnon-essential care can be maintained within reasonable limits(Buttigieg et al., 2015). Subsequently, the quality of care canimprove while savings increase. Utilization management also assumesthat there exist numerous instances of inefficient and unnecessarycare within any health care system (Buttigieg et al., 2015).Consequently, any program that lacks such assumptions should bediscontinued.

Indeed, utilization management forms an integral part in lowering thecosts of health care. Patients appreciate the provision ofcost-effective and high-quality medical care. On the other hand, manyphysicians detest the procedures and requirements placed upon themduring compliance with the program. Inpatient care is frequentlyaccompanied by health insurance. Therefore, eradicating utilizationmanagement increases the claims experience and lowers enrollment dueto enhanced costs. Programs can be evaluated using various aspectssuch as quality and the number of available resources and tools.


Buttigieg, S. C., Rathert, C., &amp von Eiff, W. (2015).International best practices in health care management.Bingley, U.K.: Emerald.

Guttner, S. &amp Soyez, K. (2015). Challenges and opportunitiesin health care management. Cham, Switzerland: SpringerInternational Publishing.

Healey, B. J. &amp Evans, T. M. (2015). Introduction to healthcare services: Foundations and challenges. San Francisco, CA:Jossey-Bass A Wiley Brand.