Utilization In Healthcare

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

An overt symptom is a poor predictor of the root cause of a failure. Errors show up far from the cause of the problem. Clusters have a lot of components.

The survey revealed that one hundred percent of the chronic population patients (including with diabetes, asthma, hypertension, and hyperlipidemia) strongly agreed that the care and education they received at the NMC helped them understand and manage their health condition. The patients also said that service was prompt and quick. Most patients expressed gratitude for the creation of NMC. From what I read, NMCs are a positive contribution to the health care system. Patients with chronic health conditions will be better managed and will eventually decrease emergency room visits and hospital admissions due to exacerbations of these conditions. Only weakness to this system is the financial funding. In order for the NMCs to sustain, adequate financial support is vital. As a mission-driven service, nurse managed health clinics (NMHCs) face monumental tasks in obtaining financial resources to maintain the center (Esperat, Hanson-Turton, Richardson, Debisette, & Rupinta, 2012). It is a virtual certainty that a significant proportion of the services provided will have to be cross-subsidized through more stable revenue resources, such as those acquired through commercial and managed care contracts. The potential to obtain long-term and sustainable resources for NMHCs requires the ability to participate credibility in the healthcare marketplace, and to engage in the competition for commercial and private

The role of human resources is also very important in maintaining an effective health care industry. If the managerial personnel are performing their duties effectively and efficiently in a health care organization, the organization will automatically progress. Additionally, the organization will provide the improved outcomes of the patient health and health care delivery as well. This is so because human resource is also considered as one of the most important inputs to effective health care services. Although there exists a variety of challenges in inducting qualified human resource professionals but there is a strong need to solve this issue. (Kabene, 2006)

The Industrial era, starting after the Civil War and ending at the end of the 19th century, was a significant time in American history. To determine the discontent of farmers, all aspects of the Industrial era must be analyzed. Socially, the farmers represented the widening of the classes taking place at the time. Economically, they were the embodiment of the struggling lower and middle class. Politically, the farmers discontent did not go unnoticed as the two party system was disrupted by a surging new third party, the populists. The farmers discontent affected many parts of the American society at the time, and had a major effect on politics.

enhance quality. Some of the nursing issues in health care reform are; access to care,

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

Nursing shortages have been an issue in the health care field for a few years now. This shortage is seriously impacting nursing homes and the elderly in our society today. With a shortage of 8.1% of nurses in 2008, it is important to understand what is happening to nurses (Addressing the Nursing Shortage, 2010). To help one understand the nurse shortage more, this paper will discuss resource scarcity, stakeholders, economic flows, changes in supply and demand, pricing decisions, along with a business proposal. The business proposal will discuss where the market has a shortage of providers, list of services the firm will provide, explanations of set prices, and who will be hired and how much one will be

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.

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.

One of the aims of the Patient Protection and Affordable Care Act (ACA) of 2010 is improved integration and coordination of services for primary patient care. The patient-centered medical home (PCMH) is one of the approaches by which improvements can be established. The patient-centered medical home model is particularly well-suited for people who have chronic illness. The design of the patient-centered medical home model departs substantively from traditional reimbursement policies, in that, the ACA provides for incentives and resources to enable care coordinators to be directly recognized and compensated for their care coordination work. Care coordinators are most often registered nurses who through their work that aligns with ACA engage in quality improvement work, cost-effectiveness measures, and patient advocacy. To bring the ACA model to a human scale, the authors present a case study of a care coordinator at a patient-centered medical home in rural Maine. The table provided below provides a basic textual analysis of the study as it is published in the professional nursing journal.

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.

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”.

Nurses in the healthcare field have the ability to work and see their patients regularly. There is an obligation to our patients, to provide the best care possible. Our patients need to be safe in our care and have their needs met. To ensure that patients receive the best care possible, health care providers need to be able to address any problems that they may face, or that their patients’ are facing. Patients may face the dilemma of not having access to quality health that is affordable. Race and socioeconomic are two influencing factors that influence the type of care a patient might receive. Not having the access to healthcare can impact an individual’s health. A nurse is able to address this issue, by education. Educating lower income families about various options can help overcome this disparity. Nurses as well can also help address disparities by

Ancient Egypt Transformed: The Middle Kingdom exhibition at The Metropolitan Museum of Art, New York