Utilization management in health care

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:

1. 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).
2. 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?
3. 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?
4. 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 https://youtu.be/g-T-YeP53nY

Carasso, S. (2017). Is that test necessary? The key to laboratory utilization management.
The Journal of Medical Practice Management: MPM, 33(3), 160-164. 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), 623-631.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), 2532-2537.
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, 133-144. 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), 1067-1073. Retrieved from the Trident Online Library.