Discuss the concept of managing utilization. Incorporate into your discussion the role of the provider Answer

Discuss the concept of managing utilization. Incorporate into your discussion the role of the provider and case management. Describe the differences in managing the utilization for acute-care patients versus chronic-care patients.

There are two(2) primary means of measuring utilization are:

  1. Physician-Utilization Data – with this type of data, there are no set standards for reporting data on referral utilization. Unfortunately, the process of counting only the initial referral or authorization often results in the omission of a large portion of actual utilization. When using hospital-utilization data, a choice must be made as to what will be measured, and that measurement must be precise.
  2. Hospital-Utilization Data – this data may vary by geography and by practice.

“Hospital utilization has been decreasing for many years, though there has been a rise in the admission rate for individuals over the age of 65. Much of this is a result of the effect of managed care over the past few decades as well as advances in medical technology that enable care that once required an inpatient stay to be delivered in the outpatient setting. Furthermore, decreasing hospital capacity also has a strong effect because fewer beds mean tighter criteria for admission. In all events, the net result is that when patients are admitted to the hospital, they are considerably sicker than they were 20 years ago, and they require concomitantly higher levels of clinical resources.”

(Kongstvedt, p. 137)

PCP plays a key role in the utilization-management system. For example, if a member wants to be seen by a physician, he or she may visit a PCP without any barriers to access. However, if the patient requires the expertise of a specialist, the member must obtain authorization from the PCP before scheduling any specialty-care appointments. If the member does not obtain authorization, the plan has the right to deny payment for unauthorized services (an HMO plan), or it may offer a lower level of payment (a POS plan). The process of authorization is specific to each managed-care program. For example, some systems allow only one visit per authorization. These systems, called single-visit authorization systems, provide the highest degree of utilization management. Patients with a chronic disease may be better served by the specialist versus the PCP. In these circumstances, the specialist may act as a PCP.”

Utilization management is the “evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan,” according to Wikipedia source. This type of review involves case analysis and a follow up of procedural recommendations.



Utilization management describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers pre-emptive processes, such as concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient. Utilization management is prospective and intends to manage health care cases efficiently and cost effectively before and during health care administration, as opposed to utilization review that are more retrospective and consider whether health care was appropriately applied after it was provided.

Evidence demonstrates that a high degree of unwarranted variation exists in the practice of medicine: patients may be overtreated, undertreated, or treated with the wrong interventions. This unwarranted care can be further categorized into three situations:

  • Use or lack of use of evidence-based medicine: In this situation, a care plan is proven to be effective, and there are no significant “trade-offs.” For example, use of a beta blocker for patients post heart attack varies widely,1 although it should be nearly 100% because clinical contraindications are rare.
  • Preference—sensitive care: In this situation, a choice is involved (trade-offs) because at least two valid alternative treatments are available. For example, in southern California, a patient is six times more likely to have back surgery for a herniated disk than in New York.*
  • Supply—sensitive care: In this situation, the more available a treatment is, the more often it is used. For example, per capita spending per Medicare enrollee in Florida is more than twice that seen in Minnesota.2

Managing utilization involves managing the processes of care, which requires a system approach that coordinates services, eliminates redundancy in care delivery, and makes use of alternatives to traditional methods of meeting healthcare needs. On the caregiving level, internally developed benchmarks illuminate efficient or unneeded practice patterns, hospitalist programs help contain inpatient costs, and standard protocols and disease state management help to maintain expected measurable outcomes. Wisely managing patient access to care, relying upon case managers to oversee catastrophic care, assessing high-risk senior citizens and promoting their and other patients’ relationships with social service agencies, and implementing patient education and prevention programs all can be coordinated within the managed care system. There for chronic-care patient require more day to day care where acute is more immediate assistance.

Utilization Management is one of those areas were everyone thinks they know exactly what it is but really can’t give a full description. UM managers generally have a very stressful job and can vary based on where they work.

Discuss the concept of managing utilization. Incorporate into your discussion the role of the provider and case management. Describe the differences in managing the utilization for acute-care patients versus chronic-care patients.

Management utilization is a program that is focused on reducing the number of inpatient admissions, eliminating unnecessary hospital days, reducing unnecessary procedures, and reducing the need for specialist referral. The role of the provider can be anywhere from collecting data regarding diagnosis, required services, test results, review of those criteria’s, comparison of medical records, physician referrals, needs, and the critical nature of the patients. The role of the case management is to allow divergent healthcare professionals to manage and resolve issues surrounding patients. These tasks include assessment, planning, facilitation, advocacy, and recommendations.

The difference in managing the utilization for acute-care patients versus chronic-care patients is in acute-care, the issue is immediate and triage, or management of resources, takes a second step of the urgency and critical care nature of the patient. With chronic-care patients, utilization management is directed more at the appropriateness of quality care without the overuse or overspending of unnecessary resources.

Management of care is very important in the hospital setting due to abuse of services that end of being billed to insurance companies. Often times patients are kept as inpatient or as an observation patient with no just cause for keeping them there. This could be poor case management on behalf of the hospital and the physician. Utlization review is definitely the department along with case management that is suppose to help to eliminate this type of mistake from happening. Often times when a patient is admitted into a facility and precert is done or there is an authorization for services or an extended stay, progress has to be called into the insurance company as to the patients status in order to grant them additional days of stay within the hospital or to have an additional procedure approve prior to the insurance company agreeing to pay for services being rendered.

Utilization management benefits the patients and the health care providers by helping patients receiving the most appropriate care. Utilization management is the collection, assessment of monitored data that permits patients services and treatment. Utilization management aspects are patient care; meaning the timeless of service, the number of hospital bed used in a day, amount of medication prescribed and recovery time of patients.


Acute care patients require managing based upon sudden illnesses and they are severe. There may be a illness that is sharp pain and results is symptoms appear and then, change to get worse. There is a need for managing care to respond quickly because it could mean death soon and usually it is a severe situation. Managing this type of illnesses usually not long term. The chronic care patients is based upon long terms and what areas of problems to focus disease or issue of more than a year and it is ongoing medical disease. These type of patients require less time and many hours of less skilled workers and the doctor does not have to spend a lot of time with them. It seems that managing utlization focus on decision making based upon the appropriate healthcare and service needed and what type of coverage the patient has or need as per the two articles I reviewed below. Also, it is important the managing utilization evaluate, review all aspects of the health issues to determine the most efficient and logical procedures for the patient health care.



Utilization management is an organizational, multidisciplinary approach to balancing the quality, the risk, and the cost issues that can affect patient care. Utilization management is a structured process of assessing and evaluating the healthcare needs, quality, safety, and effectiveness of health care services that are provided. The overall goal of utilization management is ensure that a sense of quality and effective health care is maintained and provided to all patients based on the appropriate level of care. This helps to ensure that appropriate care is coordinated for patients, and that it is cost effective and it meets their health care benefits.

Kongstvedt, P. (2007). Essentials of Managed Health Care (5th ed). Jones & Bartlett Publishers.

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