PROVIDE A RESPONSE AND REMARKS TO THIS STUDENTS DISCUSSION POST BELOW, BASED ON YOUR UNDERSTANDING
1. Does Utilization Review (UR) constitute "practicing medicine" and if so should UR be limited to only those medical professionals licensed to practice medicine?
After a lot of reading-I believe I can understand why some would be concerned that utilization reviews would constitute "practicing medicine." The review standards are medically based criteria and not everyone participating in the process have a medical degree/license. However, the final decision in these reviews does not rely on a non-medical person's recommendation.
My understanding is that medical experts' reports and recommendations and other health care providers' reports and recommendation are relied on heavily when making the final decision. Most utilization reviews undergo a second review process referred to as medical review before going final on decisions-these reviews are not taken lightly.
"In this process, a nurse or physician reviews the record for clinical documentation to support the hospital admission and/or payment. Good documentation can be helpful to substantiate medical necessity" ("Utilization Review," n.d.). Lastly, utilization review process requires the determination of whether the care is appropriate or not be based on a licensed medical physician's decision after carefully evaluating the patient's medical condition.
2. Discuss who you think should head the utilization review program and justify your answer.
Chief Medical Officers (CMO) should lead utilization management committees. Based on their medical knowledge and healthcare administration expertise they can balance the clinical needs of the patients with cost-reduction goals. They are also able to quickly get information or have access to "experts" for a medical opinion on cases.
Furthermore, Chief Medical Officers are already able to recommend or redistribute resources to facilitate appropriate use based on the result of the reviews. The CMO position provides a perspective that allows awareness of the difficulties physicians deal with daily (Glantz, 2015).
Utilization review is about improving the quality of patient service and effective use of medical resources. Chief Medical Officers are familiar with healthcare regulations that affect payment or nonpayment of services. Hospitals need payers to pay to continue to operate/deliver care.
They have a background in Healthcare Management-training can vary but generally they "include ethical issues, finance, accounting, health services, management, and legal issues related to health care" (Schweitzer, 2017). Utilization review processes require knowledge in these areas, therefore they would be the ideal people to lead the program.