Discussion Post
Utilization management helps health care organizations control costs and improve quality. The principal objective of utilization management is the reduction of practice variations by establishing parameters for cost-effective use of health care resources.
For this discussion, you are taking on the role of the director of utilization management at Mount St. Clare Medical Center. Some practice variations have been observed among health care providers at your medical center. Your CEO asks you to conduct training for your health care providers.
• Using your own words, differentiate three basic components of utilization management: precertification, concurrent review and retrospective review.
• Using your own words, explain the importance of drug utilization review and step therapy.
• Using your own words, distinguish between disease management (DM) and case management.
• Using your own words, examine a successful DM program (e.g., Aetna Health Connections disease management program) from real-life provided by an employer, hospital, health insurer, or other entity. Be sure to address its accreditation or certification status, if any, and its impacts on health care quality and cost.