PROVIDE A RESPONSE AND REMARKS TO THIS STUDENTS DISCUSSION POST BELOW, BASED ON YOUR UNDERSTANDING:
1. Does UR constitute "practicing medicine" and if so should UR be limited to only those medical professionals licensed to practice medicine Utilization Review does not necessarily constitute "practicing medicine" per se, but it absolutely does require an extensive amount of medical knowledge to run a Utilization Review program.
Often times, it is the practice of medicine that is being reviewed. For one to claim that a provider is over or under utilizing certain services, one must have medical reasoning to back it up.
Such claims are not only very difficult for a non-physician to back up in terms of credibility, but especially difficult to create in the first place. It is a provider, often a senior physician, who can best understand the practice through empirical knowledge, and therefore the cost containment of medical practices without jeopardizing the quality of healthcare.
2. Discuss who you think should head the utilization review program and justify your answer As mentioned in the "background" section of this module, UR was originally created to contain the cost of healthcare (TUI, 2017).
If that were still the case today, I would say either a senior physician or a senior healthcare administrator could head the UR program. However, in recent years, UR programs have morphed into both a cost containment program, as well as a quality of healthcare program.
Especially as the federal government financially supports programs such as ACOs, PCHM, and payment methods such as value-based and bundled payments (Adirim, 2016). All of which require quality measures to be reported and affect the reimbursements of the organization thereof. Considering quality of healthcare is now at the forefront, I believe a senior physician is the most appropriate person for the job!