Challenges in Utilization and Case Management in Managed Care

Topic: Challenges in Utilization and Case Management in Managed Care

Students will submit their Managed Care Project in APA format and include the following.The project will be at least 5 pages not including cover sheet and citation page. Spelling and Grammar Counts.

1.Introduction
:  Students will submit a one paragraph introduction of the topic they will be discussing.

2.Body of the Paper will include the following.
•Explain your topic in detail.
•Define the Challenges and Problems with your topic.
•What are recommended solutions to the challenges and problems?
•Are there any implementation to solve the challenges and problems?
•What is your opinion on the topic and what would you do if you were in
charge to fix the problem.

3. Conclusion

4.Work Cited in APA format. Students will have at least two references.

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Running head: CHALLENGES IN UTILIZATION AND CASE MANAGEMENT IN MANAGED CARE

1

CHALLENGES IN UTILIZATION AND CASE MANAGEMENT IN MANAGED CARE 3

Challenges in Utilization and Case Management in Managed Care

Leribeth Inoa

2/23/2019

Managed care refers to the practice of managing some aspects of the medical services i.e. the cost and the quality of the medical services. Managed care can be managed by healthcare providers when providing healthcare services. Utilization management refers to the processes or the activities that are involved in the management of care. for example Uutilization management is relied on in terms of managing the cost in the health plan. It also refers to the routine functions which are utilized for the management of the cost of the medical services. Utilization management is entailing aspects such as prospective, concurrent, and the retrospective review. A prospective review is involving the process of tackling the utilization before its occurrence; con-current review is addressing the utilization as it happens; whereas the retrospective review occurs after the fact. Case management, on the other hand, is relied on in delivering substantial savings. In case of management, trained nurses are relying on the nurses to help in the coordinating the aspects of care like rehabilitation, home care, and health education thus helping in the improvement of the outcomes and the reduction of the expenses (Peter, 2019). Comment by Susan Such: I think I know what you are trying to say but you should rework the sentence. You might indicate that “managed care guidelines are adhered to by providers”. The providers don’t actually manage managed care, but they are subject to the rules of it. Comment by Susan Such: I think you could do better with this in terms of explaining the meaning. Comment by Susan Such: Process as you wrote it is singular, activities is plural. When you then have to figure out to use is or are you have an issue. Both have to be either singular or plural. Comment by Susan Such: End of sentence. Begin the next sentence with Utilization management is relied on…… Comment by Susan Such: This pretty much duplicates the previous sentence Comment by Susan Such: Aspects of utilization management are prospective, concurrent, and retrospective review. Comment by Susan Such: Explain with a bit more details. What is being reviewed?? Comment by Susan Such: In case management specially trained nurses rely on the staff nurses to help…… Comment by Susan Such: Comment by Susan Such: Is this the one paragraph introduction? There should be a paragraph that explains what the paper is intending to accomplish or teach, etc. I would say that the paragraph here is explaining your topic. But you don’t have an introduction.

Challenges in Utilization and Case Management in Managed Care

Utilization management is considered to process which have been well thought-out to help in the controlling of the medical services which are being provided by other people. Utilization management is a growing technique for quality assurance and for the containment of the cost. Managed care is an important aspect since it is directly affecting the quality as well as the availability of the medically required treatment. It is also important in discharging the plans, managing of the catastrophic cases, and the performance of other healthcare reviews (Peter, 2019). Comment by Susan Such: Introduction: Students will submit a one paragraph introduction of the topic they will be discussing.Body of the Paper will include the following.Explain your topic in detail.Define the Challenges and Problems with your topic.What are recommended solutions to the challenges and problems?Are there any implementation to solve the challenges and problems?What is your opinion on the topic and what would you do if you were in charge to fix the problem.ConclusionWork Cited in APA format. Students will have at least two references.

Case management is targeting the high cost as well as the restrained to high-risk patients who consume a uneven amount of healthcare resources. Effective case management programs have become increasingly essential within the system of healthcare. This is because it is greatly impacting on a number of factors such as the aging population, the readmission penalties, and the increasing quality reporting requirements, the expanded health insurance cover, and the payment reforms among others (Peter, 2019).

The challenges Comment by Susan Such: You don’t need this. It falls under the main heading.

Despite the importance of the two factors i.e. utilization and the case management, there are a number of challenges which are faced towards the success used of these two aspects in the managed care. Utilization management is having a challenge which is related to the limited clinical autonomy as well as being the contributory factor to the intolerable administrative burden. Some of the issues related to the utilization management are in the pharmacy whereby there is an increased risk sharing which made to be complex by the delays in the data flow and the complicated financing for example rebates to the pharmacy benefit managers which might or might not be shared with the vendors. There are also problems which are related to the communication process between the groups and the clinical providers concerning drug utilization (Flemmons & Wyatt, 2015). Comment by Susan Such: Is this taken from the source? What does it mean Comment by Susan Such: Because you don’t have an introduction indicating what you are trying to state, with this paper, the body of the paper and its meaning, gets lost. So you need to pull it together and ensure your sentences make sense.

Another challenge of the utilization management in the pharmacy benefit managers is the variations in the quality which occasionally leads to the low plan STAR ratings. There is a variation in the formularies and the distribution channels of the drugs. There is also limited best patient pricing to a single chain. There are no alternatives for the integration with other sources of drug therapy. Tiered reimbursement and prior authorizations for the specialty as well as the high-risk drugs leads to negative impact adherence and timely access. Another challenge is related to the drug reconciliation more so at the transition in care from outpatient to the institution and back (Spetz, 2015). Comment by Susan Such: You’ve done a great job with the intext citations. If there are page numbers to supply you want to add that too.

With regard to the case management, managers are faced with difficulties as well as with multifactorial responsibilities which are focused on the means of preventing, proactive interventions, and the transitions of the care. Managers are responsible for the facilitation of the care to the complex patients, for example, those who are having prolonged co-morbid illnesses and require psychosocial help, coordination of care to guarantee eminence outcomes in the highest operational fashion, reduction of the preventable hospital admissions, and reducing the gaps among others. Therefore, it is always the responsibilities of these managers to access timely data and insights with regard to the status of the patients (Spetz, 2015).

Another challenge in relation to the case management is related to the misalignment of the financial incentive. There is an increase in the site of the service reimbursement between the provision by the healthcare outpatient clinics and the non-healthcare private practice providers. This means that there is a possibility of having lower cost care to ensure equal quality thus leading to the reduction of the revenues of the case manager’s employers (Flemmons & Wyatt, 2015).

With regard to the case and the utilization management devoid of timely and information-driven acumens of the limited value, there are some substantial investments which have been made in terms of the electronic healthcare record systems which are used for the administration, financial, and the operational functionality of the organization. These incentives are important, nevertheless, there are challenges with regard to the interoperability with the legacy and other information technology systems. Rather than helping in the improvement of physician productivity, electronic medical records are becoming more focused on the administrative activities, ancillary staff, layings-off, and billing.

Recommended solutions

To address the challenges related to utilization management, it is important to have an effective solution so that there can be a successful process of managing care. In this case, it is important to have committed primary care physicians who are already practicing the primary care Medical Home Model to help in supporting the medical group. This can be achieved through having team-based care, all the team members working to the highest level of their education and licensure, the existence of robust communication systems with the patients prior to, during, and after the in-person office visits. It is also important to have a data system with Electronic Medical Record to help in the identification of the present gaps in the care, preventive requirements, and clinical pathways. Assessment in the transparency of the data related to the outcomes is important since it supports the improvement.

It is also important to have a committed network of healthcare providers from the institution to the consultant specialists. It is necessary to have prayer partners who can share accurate as well as timely data from the separate utilization management activities more pharmacy and the behavioral health and from the claims. With regard to case management, it is necessary to have human capital approaches. Some of the human capital approaches which are applicable include leadership, the recruitment process, development of the organization, and the optimization of the performance among employees. Proactive partnership amongst the patients, financiers, primary care physicians, and clinical specialists is essential.

The use of a supportive cloud-based technique, data analytics, and the governing acquiescence mechanism also forms important elements of human capital strategies which can be used to overcome the issues related to the case management in the managed care. An organization can also rely on the A & M’s clinical support services practice to help in giving registered nurses with leadership and staff status in the utilization and case management. This is important in ensuring that there is the existence of personnel who can be contacted for short-term operational and the long-term strategic needs of the organization (Spetz, 2015).

Whether there is a presence of the implementation processes towards addressing the challenges and problems

There is pharmacy Benefit Managers who are responsible for making direct contact with the payer and they rarely take financial risks for the cost of the drug benefit. The pharmacy benefit managers’ services are included in the overall administrative services for the individual funded plans. Utilization management is relying on or making claims of the data from the pharmacy benefit managers to ensure that there is effective management of the programs (Peter, 2019).

There is the presence of the peer review which is important for the establishment of the policies and the procedures to help in the assessment of the potential service or quality issue in relation to the specific providers. The policies are majorly concerning the process of care and in this case, members plans in the network provider or applying to credentialing and re-credentialing process. Peer review also involves policies and procedures related to the internal information collection which are specific to the provider.

Reflection or opinion on the topic

Utilization management and the case management in the managed care are important processes which are necessary for ensuring that there is success management process of the medical services. Usually, managed care is an important issue which is affecting the quality as well as the availability of the medically required treatment. When faced with the situation or issues related to the cost management in the firm. It is always important to ensure that the processes involving the utilization and case management are monitored are effectively managed to ensure that the cost of health care is managed effectively. A suitable process of implementing the utilization and case management is important when it comes to the balancing of the clinical needs of the patients. One of the mechanisms through which the success of the utilization and case management are achieved is ensuring that there is the existence of better design plan to help in the redistribution of the resources which are targeted at facilitating inpatient, residential, inpatient, and day hospital treatment.

Conclusions

It is important to make an effort towards the management of the cost. It is important to acquire a better price for medical services to help in the control of the cost. The success process of controlling the cost requires a combination of utilization management and care management. Utilization management involves the aspects of prospective, concurrent, and the retrospective review. A prospective review is involving the process of tackling the utilization before its occurrence; con-current review is addressing the utilization as it happens; whereas the retrospective review occurs after the fact. Case management, on the other hand, is relied upon towards delivering substantial savings.

References

Flemmons, K., & Wyatt, P. (2015). Utilization Management: CMS Guidelines for Observation and Inpatient Services. Presentation from Vanderbilt University Medical Center. Peter, K. (2019). Utlization Management, Quality Management, and Accreditation. Health Insurance and Managed Care, 153-190. Spetz, J. (2015). Too Many, Too Few, or Just Right? Making Sense of Conflicting RN Supply and Demand Forecasts. NURSING ECONOMIC, 33(3), 177.

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