Utilization management is described as the implementation of guidelines which reduce unnecessary use of medical resources (Kongstvedt, 2007, p.190). There are a variety of methods used to ensure costs are kept at a minimum without compromising patient care. The use of utilization management (UM) are yielding financial benefits resulting in managed care organizations (MCOs) and facilities investing more into UM programs.
Health maintenance organization’s (HMOs) use of the primary care physician (PCP) as the “gatekeeper” initially had MCOs view restrictions as a negative approach to patients’ choices. However, some necessary steps have started to be implemented which reduce unnecessary utilization by enforcing some restrictions. The UM applications and tools include: demand management (DM), this refers to various approaches by a health plan to ensure the most effective and necessary plan of care is provided to a patient.
DM can be provided by health plans in the form of nurse advice lines. This tool has always been available with the majority of HMO plans. It comprises of nurses that are available to answer questions to members 24 hours a day, seven days a week. This service is now emerging with PPOs, Medicare and Medicaid among others. It benefits the member by reducing trips to the emergency room due to conditions that could easily be treated in a non urgent method (Kongstvedt, 2007, p.192).
Nurses have a vital part in UM, a study done by Jencks, Williams and Coleman (2009) showed that Medicare was spending approximately $17.4 billion on beneficiaries who had been readmitted within 30 days of discharge. An additional study done by Bobay, Yakusheva and Weiss (2011) suggested that increased nursing staff prior to the patients discharge would enable UM in allowing nurses to correctly explain medications and precautions to take after discharge to avoid the patient being readmitted.
Self-care and medical consumerism programs are also a part of DM. They provide member with access to medical information that will assist them in caring for themselves and knowing when to consult a professional. These programs are now an accreditation standard for health plans by the National Committee for Quality Assurance (NCQA) as they promote consumer directed health (CDH). The benefits of self-care programs show $2.50 to $3.50 saved for every $1 invested by health plans. A HMO study done showed a decrease in outpatient visits as well as a 2:1 return (Kongstvedt, 2007, p.192). Another different study showed a decrease in pediatric acute care visits also.
Other programs under DM that have shown to be beneficial to both the members and the health plans are, shared decision-making programs and medical informatics. PPOs, HMOs and CDHPs have preventive services programs being implemented. Preventive services include services such as: immunizations, mammograms, physicals, and counseling. An independent study on an indemnity plan that had prenatal preventive...