MHA 540 CASE MODULE 2 UTILIZATION MANAGEMENT, UTILIZATION REVIEW, AND CASE MANAGEMENT ESSENTIALS

MHA 540 Case Module 2: Utilization Management, Utilization Review, and Case Management Essentials Student's Name Institution Course Code and Name Professor's Name Submission Date Resource and cost management are crucial to quality care and cost control in today's fast-changing healthcare environment. Healthcare facilities use utilization management (UM) and utilization review (UR) to achieve this balance. This paper will compare UM and UR, their roles in value-based healthcare, individual case management, ethical quality evaluations, and healthcare managers' responsibility in navigating these difficulties. UM Versus UR Despite their different goals, UR and UM are vital to healthcare systems. UR focuses on retrospectively reviewing healthcare services' appropriateness and medical necessity. Due to its retrospective nature, UR can uncover healthcare resource overutilization, underutilization, and misuse. It ensures that care delivery meets requirements as a quality control measure (Davis, 2023). Utilization management guides and regulates healthcare service use before its provision. It implements rules, norms, and preauthorization criteria to allocate resources wisely. UM examines proposed treatments and services for necessity and efficiency to reduce costs and improve patient outcomes (Othmani et al., 2019). This prospective strategy lets UM optimize real-time care delivery and resource allocation (Bauer et al., 2020). UM guides resource allocation and improves care delivery, whereas UR analyzes care retrospectively to assure compliance and quality control (Davis, 2023; Bauer et al., 2020). Thus, while the two have significant differences, they maximize healthcare utilization and quality. They aim to enhance healthcare delivery and quality. Role in Providing Value-Based Healthcare UR and UM contribute to value-based healthcare by optimizing resource utilization, improving service quality, and reducing costs. Value-based healthcare prioritizes effective patient outcomes at low cost, patient preferences, and population health (Hirpa et al., 2020). UR is integral in promoting value-based care, considering it assesses healthcare treatment appropriateness and necessity retrospectively. However, its prospective use can reduce admission rates (Desai et al., 2017). Such helps healthcare providers enhance the quality of care and reduce costs by identifying overuse, underuse, and misuse. It also enables them to evaluate evidence-based recommendations and standards, improving the consistency and quality of care (Davis, 2023). UM helps distribute resources and direct patient-centered care in real-time. By embedding clinical guidelines into decision-making processes, this policy ensures that patients receive accurate, evidence-based health services that are appropriate for their needs. This approach minimizes unnecessary utilization and preventable complications, thus leading to better outcomes for patients while reducing expenditures incurred in such futile actions (Bauer et al., 2020). UR and UM foster efficiency, effectiveness, and patient-centeredness in implementing a value-oriented medical practice. Aligning patient needs and preferences with care processes improves patient satisfaction and engagement, hence strengthening relationships between patients and providers. Such emphasizes preventive care programs, early intervention st...