The principal objective of utilization management is the reduction of practice v

Question

The principal objective of utilization management is the reduction of practice variations by establishing parameters for cost-effective use of health care resources. There are four main techniques or tools used in utilization management: demand management, utilization review, case management, and disease management. Utilization management helps MCOs control costs and improve quality.

Refer to the readings of this week and the Internet on the above information, answer the following questions:

Now, access information on disease and case management by searching the Internet by using the following keywords:

Based on your research, answer the following questions:

Please support your work of the of use outside sources. As always your sources in your work and provide references for the citations in APA format. Thank you!

Explanation / Answer

Medicaid is the best health plan anywhere. It covers almost every imaginable service, with zero payment due from the patient. In practice, the reality of Medicaid is quite different. Patients have insufficient access to health care providers and lack of coordination and continuity of care, mainly because of low payment rates; despite this, states and the federal government face rapid growth in total program costs. elect the MCO plan of their choice, so to attract beneficiaries many MCOs provide additional benefits beyond what Medicaid requires. MCOs have the ability to provide some services that cannot generally be provided in the fee-for-service framework, such as disease management and innovations in care coordination. These additional services can significantly benefit patients. In addition, MCOs can improve access to care for beneficiaries. Evidence suggests that, compared to state-run fee-for-service, managed care can reduce overall Medicaid program costs, while providing better patient outcomes.The importance to beneficiaries of setting actuarially sound rates cannot be overstated. Clearly, overly generous rates would waste taxpayer funds. However, rates that are too low also carry substantial adverse consequences. For example, insufficient rates encourage MCOs to reduce payment rates to providers. This impairs access to care by making it more difficult to enroll providers and thus negates one of the main benefits of Medicaid managed care compared to Medicaid FFS. Low rates might also encourage MCOs to take steps to cut utilization below the optimal level, and cut back on services not required by the state plan, such as disease management, on-call nurse hotlines, and additional benefits. If MCOs are not able to make up the difference by reducing utilization, payment rates, and benefits, they may withdraw from the Medicaid program, or even go bankrupt altogether. And of course, if health insurers know that rates will be too low, they may decline to enter the Medicaid business in the first place. As discussed above, it is critical for states to use the best and most relevant actuarial data available when calculating capitation rates.In general, states have several options when it comes to setting rates. In order to prevent MCOs from

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