Every patient is ensured quality care based on case via the utilization review process.
Utilization review is a series of care review procedures and guidelines designed to protect patients from care denial from payers (benefit suppliers such as insurance companies) based on the costs associated with prescribed patient care. A standard in medicine, utilization review training is an ongoing professional exercise that allows the physician to objectively review, prescribe and advocate the course of care regardless of financial pressure from managed care suppliers.
History
Although clinical pathways (guidelines for adequate patient care) have been in existence for decades, utilization review became a protected legal standard with the passing of the Employee Retirement Income Security Act of 1974. This act specifically ensured quality care for all patients, regardless of financial standing, allowing patients legal appeal in the instance of denial of care.
Review Concept
The function of utilization review training is to allow the physician to use her judgment, experience and skill to determine the best course of care for each patient. The course of treatment may include diagnosis, treatments, medications and length of stay based upon the patient's condition. Additional training to make a professional judgment can include seminars, conferences and peer review.
This treatment path may be in opposition to the objective of the managed care provider, which might suggest a different course of treatment and care based upon minimum clinical guidelines, availability of benefits and other financial considerations.
Impact of Market Pressures
The quality of care and the accompanying standards are often at odds with the financial interests of managed care providers. In many cases, the payer or benefit provider prescribes clinical care suggestions based upon a combination of the patient's medical condition and available benefits supplied by that payer. This often leaves the physician in the center of the struggle, torn between providing care based upon experience and knowledge and providing care based upon probability, actuarial science and benefits of care procedure versus the costs of that procedure.
Impact on Physicians
Dedicated to protecting the health interests of the patient, physicians are often forced to face pressures brought upon them by the constraints of managed care organizations. In some cases, they become advocates for care procedures against these organizations, using their knowledge of case history, peer review and training to attempt to balance the quality of care versus the cost of care benefits allowed by the payer.
Summary
As health-care costs continue to rise, payer providers face increasing pressure to pursue clinical pathways that provide a minimum quality of care, a reduction of treatment and a reduced length of hospital stay. Utilization review training is an effective tool to evaluate clinical procedures and patient diagnosis to ensure that every patient is protected and provided with care in a consistent manner using professional medical judgment, regardless of the payer's interests or other financial circumstances.
Tags: based upon, quality care, care based, managed care, review training