Utilization Review In Healthcare Case Study

1. What is the function of utilization review?

Utilization review is a safeguard to protect against needless and inappropriate medical care. It allows health care providers to review patient care from the perspective of making appropriate decision making, medical necessity, place of service, quality of care, and the length of hospital stay.

2. Who/what was the reason for the creation of UR?

The sky-rocketing cost of healthcare and the advent of managed care over the past four decades has led to the creation of medical treatment scrutiny and rationing, which is also known as utilization review. Utilization review by PROs was intended to supplement and monitor another reform that most viewed as much more important which was the introduction

The process of third-party financing of individual health services has stimulated substantial growth and change in health care institutions and professions, raised public expectations about the benefits of medical care, and increased the costs of that care. third-party payment for medical care services expanded from the 1930s into the 1960s, payers which were primarily insurers and 6 State insurance commissioners, who have considerable power over Blue Cross plans by virtue of their power to approve rate increases, spurred some of the utilization review and other cost-containment initiatives of these plans. The latter program also gave states an increased stake in containing health care costs.

4. Do you feel the process for reporting an adverse event is adequate enough in healthcare? Why or why not?

I do not feel the process for reporting an adverse event is adequate enough in healthcare because it does not provide an adequate assessment of clinical adverse events. This method needs to be supplemented with other more systematic forms of data collection. Structured record review which is carried out by clinicians, provides a vital component of an integrated approach to identifying risk in the context of developing safety and quality

It is used to gain an understanding of underlying reasons, opinions, and motivations. It provides insights into the problem or helps to develop ideas or hypotheses for potential quantitative research. Quantitative Research is used to quantify the problem by way of generating numerical data or data that can be transformed into useable statistics. It is used to quantify attitudes, opinions, behaviors, and other defined variables and generalize results from a larger sample population. I prefer quantitative data collection methods because they are much more structured than qualitative data collection