Utilization In Healthcare

Performance Management at Intermountain Healthcare Key Points   Operational focus - strategy rather than management. How will the organization prepare for the future if their primary customer (government) reduces spending? How will they address decreasing revenues caused by their increasing effiencies?

Operations management is the organizing and controlling of the fundamental business activity of providing goods and services to customers (Encarta, 2005). In the healthcare industry, operations management generally focuses on providing a service of healthcare to patients. An organization has three basic functional areas, and theses are: finance, marketing, and operations (Operations Management, 2004, p.4). Since operations is one of the three basic functions of an organization it holds a strong significance in the healthcare industry. The contents of this paper will explain what operations management means to the writer, and why is operations management important to a healthcare organization.

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

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.

This week’s case looks at the critical situation occurring at Riverview Regional Medical Center located in Etowah County, Alabama. The medical center, located near a strong competitor, is run by a veteran in the hospital management market, Mr Matt Hayes. Hayes is actively in the process of developing new ideas and revolutionary steps in an attempt to remain competitive in the market and regain profitability. The overall performance of Riverview Regional Medical Center appears to have decreased throughout multiple departments except outpatient surgical procedures, outpatient CT imagining, MRI imagining and inpatient MRI scans.

Throughout this course I have learned about the various challenges that impede productivity and efficiency at today’s hospitals. These issues facing the modern healthcare organization come in varying forms from technological, staffing, and financial to name a few. There are no limits to what hospitals can face in these modern technologically savvy times. Below are the major issues that today’s hospitals are facing, though there are many facets to these topics it will be described as best as possible to meet overall challenges:

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”.

Since most specialty procedures are inpatient services, EMC’s inpatient occupancy rate suffers. The occupancy rate for Emanuel Medical Center – fifty percent – is far below that of its competitors and industry benchmarks. To accompany this, EMC (on average) receives a lower reimbursement for in-patient Medicare services per patient seen in comparison to its competitors. A result such as this is correlated with directly to the fewer amount of specialty services that EMC offers. In order for Emanuel Medical Center to be able to compete with other hospitals in its service area, it is imperative that EMC evaluates what services they currently offer and are capable to offer in the future to add value to the hospital, increase its revenue stream, and expand its patient mix. Currently, Emanuel Medical Center has not succumbed to its increasing financial pressurealthough EMC has had a negative operating income for five straight years. A negative operating income places EMC at a disadvantage because it limits the hospitals ability to renovate its aging building or hire new specialists to offer revenue enhancing procedures. EMC’s competitors, on the other hand, have large sources of revenue due to their mergers with large healthcare networks such as Catholic Healthcare West. Another competitor, Kaiser Permanente Modesto Medical Center, has extremely large financial resources due to the fact

Without strategic planning, several things can go wrong including missing out on great opportunities. Strategic planning is an organization’s outline to help achieve its purpose. Although strategic planning begins at the top of the pyramid, it is more effective when it is carry out as a whole among other in the organization. Having a good internal control system in place protects an organization from high risk, fraud, and more. Jackson Memorial Hospital has several weaknesses which are similar to its competitors and other health care organizations. For instance, Mount Sinai Medical Center one of Jackson Memorial’s competitors, encountered lack of strategic planning that led to many issues such as with readmissions, surgical complications,

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.

Their existing system and reputation have already set them apart as a market leader and has proven to be a profitable setup. However, there is still an unmet demand. Option 1 to add 50% more beds may not be beneficial if we don't also increase operation. Increasing the number of bed by 50% would not be advisable unless they would add more surgeons and operating rooms because the existing operating

For several decades health care has been tied to the economy and with the current downturn we see continued efforts to control and reduce over-head costs. Health care organizations in their effort to become more efficient and address changes in the industry have altered their strategic business plans. Lee & Alexander (1999) researched organizational change in hospitals and their survival, in this paper I hope to discuss their findings and add other examples to validate their conclusions.

These health care organizations have two types of planning to follow, and they are tactical and strategic planning. When tactical planning takes place, there is a short term goal in mind (Society for Human Resource Management, 2102). The course of action for a tactical plan is to achieve a goal within a year or less time period (Society for Human Resource Management, 2102). A tactical plan has a smaller scope and shorter time span than a strategic plan (Society for Human Resource Management, 2102). It takes several tactical plans to achieve the strategic plan (Society for Human Resource Management, 2102). Strategic planning differs from tactical planning, because in strategic plan, the course of action is to achieve goals for the long term (Society for Human Resource Management, 2102). Strategic planning goals are usually wanted to be completed with five years (Society for Human Resource Management, 2102). The organization’s mission statement purpose and direction are reflected upon strategic planning (Society for Human Resource Management, 2102). Top management must view reports on operations, external environments and finances when looking to develop a strategic plan (Society for Human Resource Management, 2102). The development of tactical plans are influenced by strategic plans (Society for Human Resource Management, 2102).