Utilization management, utilization review, and case management play a crucial role in the health care system for patients, insurance companies, and health care providers. These processes aim to improve the quality of health care delivery and optimize medical services in relation to their expediency and costs. In this paper, utilization review and management will be thoroughly examined, along with the significance of ethically appropriate case management for a hospital’s performance.
Difference Between Utilization Review and Management
While utilization review and utilization management are frequently used as similar terms referring to the improvement processes in the health care system, these concepts remain different. On the one hand, both processes aim to ensure that patients receive affordable health care of the highest quality; on the other hand, they differ in consistency. In general, utilization review aims to ensure that the use of health care services is appropriate. In particular, the purpose of this process is to evaluate the quality of health care delivery that should be provided on the basis of proven methods by appropriate specialists and in appropriate medical settings. Moreover, utilization review should guarantee that health care is provided cost-efficiently and according to the latest evidence-based care guidelines. At the same time, the main peculiarity of utilization review is that it may be defined as a retrospective process. In other words, it is done on the basis of the results of health care after its completion through specific protocols in which all aspects of health care delivery to a particular patient are described.
In turn, utilization management is the process based on the results of the utilization review. It focuses on health care organizations’ policies and strategies elaborated to improve the quality of operating activities and avoid unnecessary or inappropriate care. In other words, utilization management refers to particular procedures and plans that address issues identified during utilization review for their solution. Even if utilization management identifies service metrics outside the scope of utilization review, it nevertheless ensures the development and improvement of the health care system that helps prevent patient-related and organizational issues in the future. Thus, in contrast with utilization review, utilization management is a prospective process as it occurs prior to health care delivery ensuring its efficiency.
Utilization Practices’ Roles
Utilization review is traditionally used by multiple stakeholders, including fee-for-service and public payers, managed care organizations, hospitals, and other medical facilities. They aim to ensure that health care is provided accurately in relation to cost, place, methods, providers’ qualifications, and time (Desai et al., 2017). The use of utilization review software helps “reduce the number of denied days, minimize variations in care across hospital systems through standardized criteria, and improve transparency between health care providers and payers” (Desai et al., 2017, p. 623). In general, utilization review aims to ensure the provision of quality care, reduce costs, and gain insurance approval, however, it also focuses on the well-being of particular patients. While utilization review nurses check medical records, perform case reviews, and communicate with patients, they are responsible for the appropriateness of procedures, therapies, and medication for a person’s diagnosis and overall condition.
The purpose of utilization management is to ensure that patients receive appropriate health care on the basis of their needs without unnecessary costs and excessive testing. It evaluates the expediency, relevance, necessity, and efficiency of health care services or their aspects within the framework of health care plans to determine their benefits. It is a multidimensional and long-lasting process – for instance, according to El-Othmani et al. (2019), the utilization of a bundle payment method in relation to total joint arthroplasties was evaluated for two years in order to assess how this method impacted post-acute care utilization, the length of stay, in-patient rehabilitation, and readmission. In general, the issue of raising costs plays a crucial role in the application of utilization management for their minimization.
In addition, both utilization review and utilization management have particular benefits for all stakeholders involved in it. It goes without saying that they benefit patients first of all as the improvement of health care delivery and cost practices affect their health and the availability of care. Moreover, utilization review and management allow insurance companies to optimize costs and avoid unnecessary expenditures, especially within the framework of quality care delivery. Finally, the whole health care system benefits from utilization techniques as well as they ensure high-quality and accessible health care contributing to the nation’s commonwealth.
Importance of Case Management
Individual case management is critical for a hospital’s long-term survival as it focuses on care coordination, resource utilization, and financial management to ensure that patients receive health care delivery of the highest quality. Its practice refers to the assessment, planning, implementation, coordination, monitoring, and evaluation of multiple health care services, procedures, and other options to meet a patient’s needs. Case managers ensure the collaboration of health care system stakeholders to elaborate on health care plans and maximize cost-efficient and safe outcomes for clients.
Working closely with patients, payers, and health care providers, case managers ensure their coordinated efforts that lead to appropriate health outcomes and cost-efficiency of care. They aim to empower patients by promoting their self-determination and self-advocacy, contributing to appropriate results of care after discharge as well. Moreover, case management emphasizes the significance of quality control through information management, human resource management, and the availability of relevant data that ensures the efficiency of decision-making (Parast & Golmohammadi, 2019). In addition, case management controls the provision of health care according to national standards, enhancing the patient experience and an absence of underutilization or overutilization of services. In this case, a business will be attracted by the quality of health care that allows to avoid unnecessary expenditures.
It goes without saying that quality reviews that aim to improve the quality of health care delivery frequently presuppose the involvement of patients. In this case, they should be based on the ethical principles of beneficence, non-maleficence, informed consent, the confidentiality of patient data, autonomy, justice, the opportunity to reject care, and independence. In other words, health care managers should act in the interests of patients respecting their right to make decisions and receive information concerning their health and the consequences of treatment. In addition, they should respect patients’ values and beliefs, considering them in health care delivery. Ethical pitfalls may occur when the perceptions and attitudes to particular health-related aspects of health care providers and patients contradict each other.
In addition, according to the ethical standards, health care should be delivered on the basis of patients’ health-related needs. However, in the case of insurance companies’ involvement, ethical dilemmas appear. In other words, healthcare providers should consider the financial aspect of health care delivery – thus, their freedom in medical assistance is limited. That is why utilization review and management are applied to eliminate these ethical pitfalls. First of all, care managers are responsible for appropriate health care, however, it should be patient-centered, and the provision of all necessary information for clients’ decision-making is ethical. In addition, the collaboration of all stakeholders and the implementation of various techniques to minimize unnecessary costs and services with their subsequent evaluation may reduce health care providers’ necessity to choose between costs and the quality of care.
Desai, S., Gruber, P. F., Eiting, E., Seabury, S. A., Mack, W. J., Voyageur, C., Vasquez, V., Kim, H. T., & Terp, S. (2017). The effect of utilization review on emergency department operations. Annals of Emergency Medicine, 70(5), 623-631.
El-Othmani, M. M., Sayeed, Z., J’nise, A. R., 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), 2532-2537.
Parast, M. M., & Golmohammadi, D. (2019). Quality management in healthcare organizations: Empirical evidence from the Baldrige data. International Journal of Production Economics, 216, 133-144.