Utilization management in primary care clinics: costs and physician autonomy

¶ … 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 procedure. 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).

Disease Management

Primary care clinics are most likely to be the first ones to receive information on an outbreak or learn of a potential outbreak in a community. The Utilization management guide provides procedures on actions for responding to such an outcome. This guide is given under disease management component. The disease management component entails ideal measures to take up in order to achieve desirable health outcomes for a population. The measures may include treatment procedures, preventive measures, community awareness and community confinements to contain the spread. In the undertake of the measures, the primary clinic sets goals such as reduce the spread of the disease, reduce the number of reported cases, increase the number of voluntarily tested patients, increase the number of early detection in specified ailments (Yedidia et al., 2000).

The articulation of the objectives under disease management will depend on the type of diseases and conditions in the community. The clinic needs to make an assessment on the most ideal program that would serve to attempt the objective successfully. In management of diseases and ailments in a community, exercises of disseminating of information and training to the community are part of the criterion used to assess. With a well-informed community, the clinic is better situated to manage a disease or illness. The clinic will also have attained disease management by involving the community. This serves to reduce the need for referrals to specialized hospitals and treatment for ailments that can be mediated through self-care (Yedidia et al., 2000).

Demand Management

This component deals with assessing the composition and volume of the stakeholders to the clinic services. The component considers the distribution of the population they expect to serve in relation to their age, gender, location, vulnerabilities and susceptibility. The component of demand management considers the needs of the population and designs a working measure to target and meet the needs of the population. Relevant measures of information distribution to the various sects of the population are considered and implemented. Specific planning is also made on how to attend to the different sects of the population in relation to the identified needs. Additional disbursement of general information through print media such as newsletters, and clinic pamphlets also falls under this component (Yedidia et al., 2000).

The demand management component also comprises of receiving information and feedback from the stakeholders. The community is the pillar behind the existence of the clinic, and the clinic should seek to get information from the community evaluating the services they offer. The communication aspects will also highlight to the community the challenges they face and the needful alteration and addition to service provision (Yedidia et al., 2000).

Referral Management

Under the utilization management, the referral management serve to give guidance on the measures to follow for specialized cases. This component assists primary caregivers to determine from a list of the existing specialist the persons to refer a patient to. The referral management component gives advice on the particular procedure to follow for making referrals (Bos, 2007). With the process of referrals and feedback of health outcome documented, it is easy for a clinic to maintain a preference data sheet for physicians who have a better success rating. The same documentation will serve as a measure to assess the clinic's personnel ability to understand their patient's needs and ideal attention (Yedidia et al., 2000).

Referral management also details the information about a physician availability and location. This information serves to increase the efficiency of the primary clinic in linking patient with their respective solution in time and with little hustles. Additional to the making referrals, the primary clinic can through the referral management assess the need for a locally-based physician. If there are recurring cases that need a particular type of physician, the referral management officer can highlight the trend by making reference to the referral data logs. From the observed trends in referrals additional considerations can be made to either recruit a specific physician or create a clinic day for the physician. The referral management will better facilitate the clinics capacity delivery of service and provision of solutions to the community (Bos, 2007).

Profiling

The profiling component is highly pertinent to primary care clinic since it serves to give the primary caregiver their profile in service provision. The affiliation of the primary caregiver with other organizations and physicians facilitate a niche for assessment, evaluation and feedback on service provision. The profile gives the primary care clinic an outward look of their practice and service delivery. The profile will entail medical information in comparison to other institutions offering services at similar capacity. The comparison will detail information on resource use and utilization, patient health outcomes, trends in referral, potential common ailments and ideal measures of improvement (Bos, 2007).

The profiling component of utilization management serves to give credit and suggest improvements in service. The component is relevant since it provides a yardstick for the primary clinic for areas that need improvement and commendation on areas they have successfully attempted. The profiling component is highly relevant for health care service provision since it is based in constructive criticisms and appraisals (Bos, 2007).

Peer Review

In utilization management, peer review component comprises of giving reviews to colleagues in the same work environment. The peer review exposes a health professional's diagnostic and treatment plans in a bid to assess the necessity of the measures and their health outcomes. The peer review component helps in improvement of service quality, health outcomes, resource utilization, cost effectiveness and general stakeholder's satisfaction. From the peer review component, reports are prepared to give documentation for future reference (Cabana & Lewis, 2000).

The peer review component avail information for use in managerial function such as to determining the efficacy of some clinical officers, nursing staff and physicians. The review provided through this component can be used to assess the clinics efficacy through its staff, determine appropriate corrective measures and changes of staff position. Changes of staff position refer to the employee appraisal process. The clinic can also use the report to recommend an addition to their staff number given the inadequacy observed in the current composition of staff given by the peer review report. The peer review reports can also serve as a source of information to the accredited board of physician recommend certain types of diagnostic and treatment measures observed to be highly successful (Cabana & Lewis, 2000).