Health Care Utilization Paper

The healthcare industry is one of the fastest growing industries. Changes are always happening in the healthcare field and new trends are created. As a worker in the healthcare industry, there are many changing aspects of the industry. At my company, I’ve noticed some of the trends that are shaping the direction of the company in a very dynamic and valuable way. Working remotely, the Affordable Care Act (ACA), and Big Data and Cloud Computing are some of the trends that my company is moving towards. While these trends are making an impact on the company, there are still challenges with the Affordable Care Act. It has been reshaping the healthcare system both positively and negatively since it was introduce.

The Case Management program is offered by Kaiser Permanente to support members with complex medical, psychosocial, and care management essentials. This specialized service is provided by case managers. The case managers are either Registered Nurses who are certified in case management or qualified Social Workers. Case managers provide necessary information and education to promote understanding, reduce the chance of possible complications, and facilitate effective and proper delivery of care and services.

The utilization review process is a health insurance company's opportunity to review a request for medical treatment. The purpose of the review is to confirm that the plan provides coverage for your medical services. It also helps the company minimize costs and determine if the recommended treatment is appropriate. A utilization review also gives you the opportunity to confirm that your health plan provides adequate coverage for your particular condition. If the company denies coverage as a result of a utilization review, you can always appeal the decision. The three steps in medical necessity and utilization review are: initial clinical review, peer clinical review, and appeals consideration. The UM is often used interchangeably with utilization

The Affordable Care Act was signed into law March 23, 2010 by President Barack Obama; however, the constitutionality of the law remained in question. In a controversial 5-to-4 ruling, The U.S. Supreme Court upheld the law on June 28, 2012. The ACA is thought by some as the United States health care rescue, and as its downfall by others.

Over the past decade, government operated and privately owned health care organizations have made improvements identifying patient disabilities, discovering alternative treatments at the patient’s discretion, identifying the cause of diseases, and discovering lifesaving cures. The current United States health care delivery system has undergone enormous changes throughout the years. People the United States utilize health care services for many reasons: to prevent disease, to prevent future illnesses, to eliminate pain, and promote a healthier lifestyle to patients. The Patient Protection and

Many factors can influence a person’s access to health care. Age can influence access to health care because some physicians will treat only children or only the elderly. Income can influence access to health care because specialty driven health care usually involves significant out-of-pocket expense to the patient because some procedures are not covered by health insurance. Location also can be an influence on access to health care. Many patients do not have transportation because of age, dependency on family members, health reasons, or financial reasons. According to the Journal of the National Medical Association, Access to health care can influence the prevalence of chronic disease risks and cancer screening utilization in many ways (Shavers, Shanker, Alberg, 2002, p. 955). If patients are not given

One possible solution for the state and/or local government to consider would be to offer state funding for patients with chronic illnesses to be covered by a state funded insurance plan based on the patient’s income. This would allow for Mr. Davis to be seen for routine care, in an attempt to keep him healthy and reduce emergency room visits and hospitalizations. Another possible solution would be for local and state governments to fund healthcare facilities and/or clinics designated to care for patients with chronic health conditions; providing public health nurses who are available to visit the patients in the home in order to educate him or her on disease and disease processes.

The Patient Protection and Affordable Care Act of 2010 (PPACA) was designed to decrease health care costs and require health care access to all U.S. citizens. The Act has the potential for reducing the cost of health care in the United States; however, with many risks which could possibly strain the health care system, increase debt, and decrease the quality of care many are concerned.

As mentioned previously, another factor that may contribute to disparities in care is the choice of location for a practice. Many patients, particularly those who are economically disadvantaged, may have difficulty commuting to a practice that is far from their community, especially if it is outside of the area serviced by public transportation. Furthermore, even if they can make it to the practice, they may be placing themselves at an even further economic

The bottom line we need to concentrate on cutting cost of health care and quality care, which we all deserve as human beings. There is not just one factor that contributes to the health expenditure but several pieces to this puzzle that makes this a major health cost issue. We need to find ways to decrease spending too much, so people can benefit from their health plan. The nation should consider cutting hospital care, clinical services and prescription drugs, since these are the top expenses for health care. This would definitely clear a path for reduced cost. The public can barely afford to pay premiums to their private health insurance companies but if they want coverage they have to pay. The one’s who qualify for Medicare and Medicaid will get help from this government program for health care cost and yes some

‘Some counties don't have certain types of doctors” (Leonard 2). If an individual only has one insurer that supports that area, that insurer may not cover that doctor or hospital in that area, which can result to that individual driving far out of their area, just so they can see a doctor or get their medical treatment for a reasonable price. Individuals are also being limited with options because their insurers may see them as costly, and they could force the individual to go to under resourced hospitals (Goodnough 3). This shows that even if an individual does not live in a rural area and has plenty of options to choose from, they can still be limited in location because their medical treatment can be seen as too expensive, and the insurance company has to figure out a way to save money.

In recent years, health care has been a huge topic in public debates, legislations, and even in deciding who will become the next president. There have been many acts, legislations, and debates on what the country has to do in regards to health care. According to University of Phoenix Read Me First HCS/235 (n.d.), “How health care is financed influences access to health care, how health care is delivered, the quality of health care provided, and its cost”.

Recognizing this growing problem, some physicians around the country have decided to tackle this issue. This paper will explore the problem of people being unable to access continuous healthcare as well as some reasons why this occurs. It will also reveal a new initiative called the Student Ho Spotters Program that has been created and tested out at hospitals around the country that aims to get people the established care that they need.

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.

She suggest that funding needs to be increase to accommodate the elderly and disabled (Linda, 2014). The second Article called the “Transportation Barriers” Author Cronk informs about the struggles and frustration the elderly and people with disabilities face due to the lack of transportation services available to them. Furthermore, the author tells the story of an elderly man who was taken to the hospital by ambulance. But, on the day of his release from the hospital he had no family nearby and had no way to get home nor had money to pay for a taxi. The hospital was unable to assist him financially to pay for a cab, frustrated the elderly patient told his nurse he would walk eight miles to his home. Cronk informs that in populated communities although many people live near doctors and hospitals they continue to face the issue of poor transportation due to financial struggles. The author states that for those who are disabled riding public transportation becomes a great challenge. In addition to missing important preventive care appointments because they have no reliable access to transportation. Cronk states that the problems were worst among minorities, stating that a high percentage of disabled and elderly patients have missed appointments due to not having accessible transportation. Cronk continues to inform that many times they just wait for medical emergencies to visit a doctor. To