¶ … Management Utilization management has in the recent past sparked heated arguments in the health sector with controversies arising as to the needs for the interventions. Medical practitioners heavily criticize the practice considering the increased workload it presents to them. Utilization management in primary care clinics presents a rigorous exercise for the patient and the medical professionals. Right from the initial patient data taking process to testing, treatment, admission, medicine prescription and discharge, the process requires precise record taking and follow of procedure (Yedidia, Gillespie, & Moore, 2000). Physicians consider the requirements stipulated in Utilization management to curtail on their autonomy and a burden in terms of the administrative work. The processes despite being rigorous and cumbersome to both the patient and the medical personnel, they influence the optimal utilization and management of health service as well as influencing a positive treatment outcome (Yedidia et al., 2000).

Utilization management covers the measures put in place to govern over or underutilization of health services. The aim in utilization management is to attain the most appropriate setting in care delivery and access (Emmons & Chawla, 1991). According to World Health Organization (WHO) primary health care refers to the universally substantive health care that is accessible through acceptable means to individuals and their families within the community at an affordable cost by the community or the government (Emmons & Chawla, 1991).

Utilization management presents an opportunity for carrying out evaluation for a patient's need for treatment, comparison of previous and current tests and assessment of the most ideal form of treatment given the prevailing patient's condition. From the institute of Medicine, utilization management comprises a combination of techniques undertaken by medical personnel on behalf of the health benefit purchaser (financer) in a bid to manage accruing costs and providing justification for procedural undertakings (Al Doghether & Al Megbil, 2004). In effect the practice of utilization management ensures minimal variations in clinical practices through established guide lines to attain cost effective delivery of health care (Bos, 2007). From the guide lines a measure of best practices to practice medicine are deployed and followed all through.

Utilization Management in Primary Care Clinics

The core argument for instituting utilization management within health facilities and the practice is to ensure that the invaluable resources are put to proper use for ideal interventions. Utilization management safe guards against use of resource for measures that do not foster quality care. The practice seeks to reduce unfitting variations in the medical practice and promote cost-effective medical interventions (Al-Doghaither, Abdelrhman, Saeed, & Magzoub, 2003).

Minimization of Variations

The duty to record information and submit repots in the practice of medicine has contributed to a sizable volume of information. The information gathered from the various source may depict a substantial degree of variation. From studies undertaken evaluating the differences in the clinical procedures, it is noted that some of the different measures did not necessarily contribute to patient's health outcomes (Cabana & Lewis, 2000). Studies in the field of utilization management observe that although a patient may be admitted to hospital care for a longer time due to severity of an illness, the patient's health outcome seem lower. The comparison after adjustments for severity indicates that the differences in medical procedures have little impact on quality health outcomes (Cabana & Lewis, 2000).

Since optimal practice and outcome is a concern for utilization management, the need to reduce variations in health practices is thus justified and upheld. Through reduction of practice variations, an accurate prediction on the needful resource can be made and a cost outlay be easily planned. Working within the confines of a given budget will also ensure that primary care clinics are manageable and sustainable for the good of the community. With the standardization of health care practices it will also be possible to attain desirable health outcomes at an ideal cost. With the health practitioner seeking to provide account of the best practice, patients health outcomes will also be appropriate. The standardization of the practice will also protect against resource misuse and prescribing of treatments that do not target optimal health outcome (Cabana & Lewis, 2000).

Cost-Effectiveness of Health Outcomes

A cost-effective clinical procedure is one that considers that cost incurred to realize a targeted health outcome. Medical personnel ought to assess the cost of a particular clinical procedure against other therapeutic or diagnostic procedures and the expected outcomes. An assessment needs to be conducted on the effectiveness of the procedure in attaining an effective health outcome. Utilization management opposes use of an expensive medical procedure that yields results similar to those for a cheaper medical...

The expensive procedure may seem preferable to the patient given the guaranteed results in testing and treating. The expensive procedures should however, not be undertaken considering the cost strain if, an alternative measure can guarantee desirable health outcomes (Al Doghether & Al Megbil, 2004).
In many cases clinical personnel have at their disposal the resource for both expensive and cheaper measures. It is their obligation guided but utilization management practices to opt for the cost effective measure. Utilization management in this case steps in to remove personal preferences and invoke a rational measure in decision taking. The decision making pattern by different physicians in similar health situation is evaluated under utilization management to assess cost-effectiveness in perspective of the outcome.

Components of Utilization Management

Utilization management is a measure of assessing the need, efficiency and appropriateness of a health care procedural service within stipulated quality and costs guide. The measure is applied across the board by in undertaking medical health procedure to ensure standard of practice in medical procedures. The generation of a utilization management guide for a health institution may be through hiring an extern consultant or internally by the management. The generation of utilization management is through conducting a review on the health institution, its composition, the resources available and community it serves. The utilization management guide incorporates various sections relating to the health institution operations and procedures in caring for patients (Bos, 2007).

Although the utilization management does not influence the treating physician's decision in treating or undertaking a procedure, it provides a guide on how to undertake the procedures. The treating physician is however required to give a report and justification for a procedure. From this report and the health outcome the concerned medical reviewers will interrogate the procedure against other procedures considering the outcome achieved. In general the utilization management guide comprises some common and standard components with differences only existing in the details that differentiate the various health institutions (Al-Doghaither et al., 2003).

Utilization Review

Utilization review considers the resources that are put to use in the health center. The component of utilization review considers the medical aspects such as physicians, laboratory tests, ambulatory, services provided, nurses, working days, radiographic studies, prescription medicine, inpatient capacity and medical treatment procedures. In order to undertake ideal reviews, there ought to be a clearly defined clinical procedural measure and the conditions that should prevail. The obligation to provide information on utilization review is availed by the hospitals personnel in-charge in most cases the nurse in-charge of utilization review (Al Doghether & Al Megbil, 2004).

The utilization review component serves to identify the health center's capacity in provision of medical services, the resources at their disposal and the community they directly serve. The utilization review also gives the health center's administrative procedure, defining the steps taken in receiving patients, testing them, procedural diagnosis, treatment, admission and dismissal. In the utilization review, information on the categories of diagnosis, the volume of admissions and the length of stay is given. The utilization review also gives information on trends of disease treated in the hospital, the health outcome trends, prenatal and post natal care, deliveries and fatalities. The utilization reviews will also give explanation for the differences in different health outcomes in different years and the changes made to bridge difference that compromised desirable outcomes (Al Doghether & Al Megbil, 2004)

With the information obtained from the utilization reviews assessments on the desirable medical services is made. The assessment leads to drafting of proposals and making adjustments based on the approvals made for the proposals. The approvals are made depending on the attained utilization given by the utilization review report, the cost effectiveness of the requested addition and contribution of the proposed improvement to the overall health outcome of the beneficiaries. The approval is also made based on the incapacities observed of the health institution and the growing need trend for the services in the area (Cabana & Lewis, 2000).

Utilization review gives an overall assessment of the primary care clinic capacity to attend to the community need as initial contact with the community in matters of health. In the case of primary care clinic, an additional review aspect in information dissemination to the community relating to outbreaks and safety is considered (Cabana & Lewis, 2000).

Utilization review is divided into three stages each stage defining the time an assessment takes place. The three stages are prospective, retrospective and concurrent.

Prospective review is the review that occurs prior to authorization to provide service.…