UTILIZATION MANAGEMENT FOR EFFECTIVE HOSPITAL SERVICES

over the last several decades need to be consolidated and The process of utilization management in its most further advanced given the rapidly changing simple form involves matching patient conditions with demographic and epidemiological transitions seen in established criteria (2), and UM is the review of services the country. Over the last two decades, public hospitals to ensure that they are medically necessary, provided in have undergone major expansion and re-organization the most appropriate care setting, and at or above quality without achieving all the anticipated improvements. standards (3). Standardized care packages at each level and a properly

The significant health achievements made in Sri Lanka will the patient need to be in the hospital, etc. over the last several decades need to be consolidated and The process of utilization management in its most further advanced given the rapidly changing simple form involves matching patient conditions with demographic and epidemiological transitions seen in established criteria (2), and UM is the review of services the country. Over the last two decades, public hospitals to ensure that they are medically necessary, provided in have undergone major expansion and re-organization the most appropriate care setting, and at or above quality without achieving all the anticipated improvements. standards (3). Standardized care packages at each level and a properly Utilization management is the collection, assessment functioning referral system are needed to reduce and monitoring of data that pertains to patient services overcrowding of the specialist institutions and increase and treatment. UM activities evaluate many aspects of utilization of primary care units.
patient care, such as the timeliness of services, the The fact is new medicines and diagnostic and curative number of bed days used in a hospital, the amount of technologies became available much faster than new medication prescribed and a patient's recovery time, so financial resources. Therefore, no country, no matter that any unnecessary services can be eliminated at how rich, is able to provide its entire population with hospitals. The dominant utilization management every technology or intervention that may improve strategy is prior review of proposed medical or surgical health or prolong life. As an example, in 2009, the services, which includes several related techniques such British National Institute for Health and Clinical as preadmission review, continued-stay review, and Excellence announced that the National Health Service second surgical opinions (4). could not offer some expensive medicines for the Health care cost containment treatment of renal cancer because they were not cost effective (1).
The rising health care costs has contributed to a growing perception that a significant amount of medical Hospitals in developing countries are facing the care is unnecessary and sometimes harmful. Therefore, problems of Allocative Inefficiency (resources are not UM has become a strong trend in health care cost cost effectively allocated), Technical Inefficiency containment. Under UM, some decisions are not strictly (resources within a facility are used inefficiently), made by the doctor and patient alone. Instead, they are Inequity, Low Responsiveness, and poor Quality of now checked by a reviewer reporting to an employer or processes. To assure that appropriate and cost effective other paying party who asks whether or not the proposed health services are provided, health care institutions in type or location of care is medically necessary or developed countries have used Utilization Management appropriate. Also, improving relations between (UM) activities for more than 20 years. UM is not only hospitals and utilization reviewers may yield higher the process of managing costs and use of services levels of utilization review compliance and significant through effective planning and decision-making, but cost savings. also utilization management is a set of techniques used by or on behalf of purchasers of health care benefits to Components of Utilization Management in patient manage health care costs by influencing patient care care decision-making through case-by-case assessments of 1. Deciding who will be served: the appropriateness of care prior to its provision.
• clarifying definitions of categories of cases to be Process of Utilization Management served.
Process of UM gives the answers to, practice of 2. Assessing service needs and identifying desired evidenced based medicine, cost-effectiveness and outcomes: quality & safety: Is hospitalization necessary or can • Timely assessments (prior to service planning). surgery be done as an ambulatory procedure? How long • Thorough, appropriate, and objective assessments.

Conclusions • Appropriate and effective tools/instruments.
Improving health is critical to human welfare and • Clearly defined, measurable, meaningful, and essential to sustained economic and social achievable outcomes. development. All countries, rich and poor, struggle to 3. Deciding what services to provide: raise the funds required for the health services their • Matching services to assessed needs and desired populations needs or demand; and are concerned to outcomes.
provide services of good quality cost effectively. • Assuring least restrictive and most cost-effective Therefore, practicing Utilization Management will methods.
solve the problems of allocative inefficiency and low • Assuring all services are necessary and responsiveness in hospital services, and also improve consistent with law, policy and philosophy the quality of services cost-effectively.

Concurrent Review/ Discharge Planning
Concurrent review involves screening for medical necessity and the appropriateness/ timeliness of the delivery of medical care from the time of admission until discharge. The main objectives of the concurrent review process are to ensure that doctors orders are carried out in an efficient and accurate manner, to anticipate treatment, plan ahead and to continually monitor the patient's progress and facilitate discharge planning.
Discharge planning involves preparing the patient for discharge from the facility. The process includes reviewing alternate levels of care, the need for ancillary services and the potential benefits of home support.