Question

A little more challenging question: What are some of the ways utilization is managed for patients specifically during the course of a hospitalization?

Answer 1

Utilization management consists a diverse set of activities planned to influence the use of health care services and thereby constrain health care resource consumption.

Assessment of UM have generated mixed findings, with some studies showing reductions in utilization and costs and others showing little effect.

The two UM practices explained here are case management and gatekeeping.

CASE MANAGEMENT

Case management represents a highly diverse set of activities

Case management can be grouped into two broad categories that sometimes overlap. Administrative case management provides brokering services to ensure that patients obtain needed services at the lowest available price, assures that available benefits are brought to bear in a coordinated and comprehensive manner, and flexes eligibility so that patients may receive cost-efficient services not included in their original benefit package. On the other hand, clinical case management primarily focuses on optimizing clinical management and often focuses on a specific clinical condition such as diabetes or heart failure. Clinical case managers often work from evidence-based protocols and proactively reach out to patients, assisting them to better manage their illness. Increasingly, such clinical case management occurs as part of a more comprehensive disease management program. Both forms of case management are provided to high-risk patients who may require costly medical care, e.g., patients with spinal cord injuries, serious mental or substance abuse problems, or chronic illnesses.

GATEKEEPING

Physician gatekeeping has become a central feature of managed care.

Gatekeeping has both positive and negative side, for the system and for the individual. The key to resolve the issues lies in flexible and easy communication between the care providers of distinct entry points, where a GP could quickly consult a specialist to confirm or remove clinical concerns, and a specialist can pass detailed instructions to a GP for potential follow-ups. Another support to effective gatekeeping, is a thorough understanding and integration of care paths, to boost the collaboration of all parties, and to strengthen transparency.