Introduction: Components of Utilization Management
Pre-Authorization
Utilization management (UM) is an essential tool to monitor the quality and cost of healthcare services. It encompasses three main components: pre-authorization, concurrent review, and retrospective review. Pre-authorization is the process of obtaining approval from an insurer or third-party payer before providing a service, ensuring that the service is medically necessary and that the cost is reasonable.
Concurrent and Retrospective Review
Concurrent review is performed while the service is being provided. It assesses whether the service is being provided in accordance with established standards and protocols. Finally, retrospective review is conducted after the service is completed. This method is used to assess whether the service was medically necessary and appropriate for the patient’s condition.
Importance of Drug Utilization Review and Step Therapy
Drug utilization review (DUR) is an important component of UM. It is the process of assessing the appropriateness of prescribing, dispensing, and administering medications. DUR helps to identify drug-related problems, such as adverse reactions, interactions, and duplications, and to promote the safe and effective use of medications (Moczygemba et al., 2019). Step therapy is a type of DUR that requires a patient to try one or more medications before a more expensive drug is prescribed. This approach helps to ensure that the most cost-effective medication is being used.
Distinction Between Disease Management (DM) and Case Management
Disease management (DM) and case management are two other essential components of UM. DM is aimed at improving the health of patients with chronic conditions by providing interventions and education to help them manage their condition. Case management is a more general approach used to coordinate care for patients with complex medical needs. It involves assessing the patient’s needs and arranging services to meet them (Batarseh et al., 2020).
Examination of a Successful Disease Management Program
A successful example of DM is the Aetna Health Connections disease management program. This program is designed to improve the health of high-risk individuals by providing personalized care management. It is accredited by the National Committee for Quality Assurance and has been shown to reduce the total cost of care while improving health outcomes.
Conclusion
In conclusion, UM is a valuable tool used to monitor the quality and cost of health care services. It includes pre-authorization, concurrent review, and retrospective review. DUR and step therapy are important components of UM that help to ensure the safe and effective use of medications. DM and case management are also important components of UM that help to coordinate care for those with complex medical needs.
References
Batarseh, F. A., Ghassib, I., Chong, D., & Su, P. H. (2020). Preventive healthcare policies in the US: Solutions for disease management using Big Data Analytics. Journal of Big Data, 7, 1-25.
Moczygemba, L. R., Alshehri, A. M., Harlow 3rd, L. D., Lawson, K. A., Antoon, D. A., McDaniel, S. M., & Matzke, G. R. (2019). Comprehensive health management pharmacist-delivered model: impact on healthcare utilization and costs. The American Journal of Managed Care, 25(11), 554-560.