UTILIZATION MANAGEMENT

/in /by

QUESTIONS TO BE ANSWERED ARE IN GREEN.

·       QUESTIONS HAVE MULTIPLE PARTS – BRIEFLY ANSWER EACH PART.

·       ANSWERS SHOULD BE SHORT – 3-4 SENTENCES PER QUESTION.

·       SINGLE SPACED.

·       12 POINT TYPE.

·       DOWNLOAD THE QUESTIONS FOR THE FINAL, WRITE ANSWERS UNDER THE QUESTIONS, AND SUBMIT THE FINAL DOCUMENT VIA THE ASSIGNMENTS PROCESS.

QUESTION 1: TWO KEY APPROACHES TO PAYING PROVIDERS.

USING ATTACHED READING 1 (SLIDES 5-6, 13 – 15)), AND READING 2., ANSWER THE FOLLOWING:

PART A:    What is the basic difference between Fee-For-Service Payments and Bundled Payments as the two (2) main approaches to paying providers for Personal Health Care Services?     (HINT: How do those terms relate (respectively) to the restaurant terms A La Carte and Prix Fixe?)

PART B: Give ONE (1) example of a Fee-For-Service Payment, and ONE (1) example of a Bundled Payment, for specific types of clinical providers (Doctor, hospital, Skilled Nursing Facility).

PART C: Give ONE (1) positive effect of Fee-For-Service Payment on the behavior of a clinical provider, and ONE (1) positive effect of a Bundled Payment on the behavior of one or more clinical providers.

QUESTION 2: PAY FOR PERFORMANCE: THE CONCEPT/ RELATIONSHIP TO PERFORMANCE MEASURES

USING READING 1 (USE SLIDES 11-12), READING 3, READING 3.A., READING 4., READING 4.A., AND READING 4.B. ATTACHED, ANSWER THE FOLLOWING:

PART A:    What is the basic premise of Pay-for-Performance (P4P) – In other words, how is this form of payment expected to positively impact on the behavior of clinical providers? (Doctors and hospitals, for instance.)

PART B: What is a Quality Measure or Performance Measure/Indicator – how are such Measures related to the concept and practice of Pay-for-Performance?

NOTE: JUST USE READINGS 4., 4.A., AND 4.B. TO GET A GENERAL SENSE OF PERFORMANCE MEASURES, WHAT THEY ARE, AND WHAT THEY DO. DO NOT GET INTO THIS IN TOO MUCH DETAIL – LOOK AT 4.B. TO LEARN WHAT HEDIS IS, AND TO GET A COUPLE OF EXAMPES.

QUESTION 3: BUNDLED PAYMENTS: PRINCIPLES/EXAMPLES/MEDICARE/MS-DIAGNOSIS RELATED GROUPS

USING ATTACHED READING 1(SLIDES 6, 13-15), READING 5.A., AND READING 5.B.

PART A:    USING DIAGNOSIS RELATED GROUPS (DRGs) AS AN EXAMPLE:  Briefly describe the basic concepts behind Bundled Payments – include ONE (1) expected Positive outcome of this kind of payment.

PART B: What types of clinical groups (patients with specific diagnoses, patients receiving certain surgical or medical procedures) are the best candidates for creating Bundled Payments? Why are they the best candidates?

QUESTION 4: DISEASE MANAGEMENT AND POPULATION HEALTH

USING READING 7, READING 6.A, READING. 6.B., AND READING 6.C. ANSWER THE FOLLOWING:

PART A: Disease Management is based on a Population Health approach to looking at clinical data. BRIEFLY: What is a Population Health approach?

PART B: Briefly indicate TWO (2) ways in which Disease Management and Case Management are different Utilization Management approaches.

PART C: Briefly discuss how Disease Management emphasizes Coordination of Care for identified populations of potential high utilizers of Personal Health Care Services, including individuals with multiple chronic conditions. (HINT: Think about Collaborative Practice Models, and Routine Reporting between Providers and Health Plans.)

QUESTION 5: IDENTIFYING AREAS ON WHICH TO FOCUS UTILIZATION MANAGEMENT

USING READING 8 (SLIDES 5 – 10). ANSWER THE FOLLOWING:

PART A:  Briefly describe Hospital Acquired Complications and Conditions: What are they? Give ONE (1) example.

PART B:  Why do you think that computer analysis of the incidence of these kinds of events (for instance, at a hospital) can help to focus efficient and effective Utilization Management activities? (HINT: Do clinical providers and administrators in hospitals have control over the occurrence of these events?)

QUESTION 6: CURRENT TRENDS IN UTILIZATION MANAGEMENT: COMPUTER ANALYSIS OF LARGE DATA SETS/IDENTIFICATION OF HIGH UTILIZERS/ADDRESSING BOTH CLINICAL AND SOCIAL NEEDS OF PATIENTS.

USING READING 7 AND READING 10.B., ANSWER THE FOLLOWING:

PART A: What kinds of data did the Hot spotting Model used in Camden New Jersey use to identify the highest utilizers of Personal Health Care Services?

PART B: Using this Reading, and the example of an individual clinical intervention in the Reading, describe ONE (1) way in which this Utilization Management approach focused on Social aspects of the patient’s life in order to improve their health status.

 
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