CONSIDERATIONS – Class 5
1. There are some people in the managed care industry who say Utilization Review (“UR) increases the quality of care while reducing costs. On the plus side: List what you consider to be the advantages of UR in terms of quality of care and cost management. On the minus side: List the disadvantages of UR. If you need help with this analysis, consider the following four perspectives: Employer Group, Providers (hospitals/physicians), Insurers/HMO’s (PPO’s), and Patient.
2. Role play from the Employer Group, Insurer, Physician and Patient perspective the following scenario:
A patient wants some very costly medical treatment that is considered experimental by the Patients HMO (insurer) and the HMO (insurer) denies paying for the cost of medical treatment.
3. If you were a buyer of health care such as for an Employer Group, how would you measure “quality”.
4. What would you do if you were a psychiatrist and many of your patients cannot receive the services that you think are necessary because their health care insurer (1) denies or limits their mental health coverage or (2) the request for services does not fit within the insurer’s utilization review department’s standards.
5. Analyze quality assurance and utilization review from each of the following perspectives: Employer Group, Insurer/HMO, Physician, and Patient.
6. Give three examples of inappropriate utilization and suggest alternatives for each that improves efficiency.
7. Explain the concept “total quality management” and the process of utilization review.
8. Describe advantages and disadvantages of “critical pathways”, “benchmarking”, and “electronic medical records”.
9. If, theoretically any service that can be described in quantitative terms can be outsourced, then consider what this means to providers. Do you think health systems will ever become “virtual integrated health systems” where services, other than governance and clinical quality, are outsourced? List your reasons, why or why n
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