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Utilization Management
Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Critics have argued that if cost cutting by insurers is the focus of their use of UM criteria, it could lead to healthcare rationing by overzealous denial of care as well as retrospective denial of payment, delays in care, or unexpected financial risks to patients. Aspects Utilization Management is "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision," as defined by the Institute of Medicine (IOM) Committee on Utilization Management by Third Parties (1989; IOM is now the National Acad ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Managed Care
The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care ("managed care techniques"). It has become the predominant system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010. ...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The p ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Avedis Donabedian
Avedis Donabedian (7 January 1919 – 9 November 2000) was a physician and founder of the study of quality in health care and medical outcomes research, most famously as a creator of The Donabedian Model of care. Early life Avedis Donabedian was born in Beirut, Lebanon, in an Armenian family from Turkey. Although the rest of his parents' families perished from the Armenian genocide, Donabedian's immediate family was able to escape, ultimately migrating to Palestine. His father had qualified as a doctor at the American University of Beirut in Lebanon and soon after set up practice in the small Christian town of Ramallah, near Jerusalem. Donabedian received his early education at the Friends’ (Quaker) school there and subsequently followed his father in studying medicine at the American University of Beirut. Career Donabedian received the degree of BA in 1940 and MD in 1944 and subsequently worked at the English Mission Hospital in Jerusalem, making a brief trip to England. ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Industry Self-regulation
Industry self-regulation is the process whereby members of an industry, trade or sector of the economy monitor their own adherence to legal, ethical, or safety standards, rather than have an outside, independent agency such as a third party entity or governmental regulator monitor and enforce those standards. Self-regulation may ease compliance and ownership of standards, but it can also give rise to conflicts of interest. If any organization, such as a corporation or government bureaucracy, is asked to eliminate unethical behavior within their own group, it may be in their interest in the short run to eliminate the appearance of unethical behavior, rather than the behavior itself, by keeping any ethical breaches hidden, instead of exposing and correcting them. An exception occurs when the ethical breach is already known by the public. In that case, it could be in the group's interest to end the ethical problem to which the public has knowledge, but keep remaining breaches hidden. ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Emergency Department
An emergency department (ED), also known as an accident and emergency department (A&E), emergency room (ER), emergency ward (EW) or casualty department, is a medical treatment facility specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance. The emergency department is usually found in a hospital or other primary care center. Due to the unplanned nature of patient attendance, the department must provide initial treatment for a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention. In some countries, emergency departments have become important entry points for those without other means of access to medical care. The emergency departments of most hospitals operate 24 hours a day, although staffing levels may be varied in an attempt to reflect patient volume. History Accident services were provided by workmen's compensation ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Anthem (company)
Elevance Health, Inc. is an American health insurance provider. The company's services include medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans through affiliated companies such as Anthem Blue Cross and Blue Shield, Empire BlueCross BlueShield in New York State, Anthem Blue Cross in California, Wellpoint, and Carelon. It is the largest for-profit managed health care company in the Blue Cross Blue Shield Association. As of 2022, the company had 46.8 million members within their affiliated companies' health plans. Prior to June 2022, Elevance Health was named Anthem, Inc. Based on its 2021 revenues, the company ranked 20th on the 2022 Fortune 500. History Anthem In 1946, Anthem began in Indianapolis, Indiana, as Mutual Hospital Insurance Inc. and Mutual Medical Insurance Inc. The companies grew significantly, controlling 80% of the medical insurance market in Indiana by the 1970s. In 1972, The two firms, then known as Blue Cross of Indian ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Emerging Technologies
Emerging technologies are technologies whose development, practical applications, or both are still largely unrealized. These technologies are generally new but also include older technologies finding new applications. Emerging technologies are often perceived as capable of changing the status quo. Emerging technologies are characterized by radical novelty (in application even if not in origins), relatively fast growth, coherence, prominent impact, and uncertainty and ambiguity. In other words, an emerging technology can be defined as "a radically novel and relatively fast growing technology characterised by a certain degree of coherence persisting over time and with the potential to exert a considerable impact on the socio-economic domain(s) which is observed in terms of the composition of actors, institutions and patterns of interactions among those, along with the associated knowledge production processes. Its most prominent impact, however, lies in the future and so in th ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Blue Cross And Blue Shield Of Minnesota
Blue is one of the three primary colours in the RYB colour model (traditional colour theory), as well as in the RGB (additive) colour model. It lies between violet and cyan on the spectrum of visible light. The eye perceives blue when observing light with a dominant wavelength between approximately 450 and 495 nanometres. Most blues contain a slight mixture of other colours; azure contains some green, while ultramarine contains some violet. The clear daytime sky and the deep sea appear blue because of an optical effect known as Rayleigh scattering. An optical effect called Tyndall effect explains blue eyes. Distant objects appear more blue because of another optical effect called aerial perspective. Blue has been an important colour in art and decoration since ancient times. The semi-precious stone lapis lazuli was used in ancient Egypt for jewellery and ornament and later, in the Renaissance, to make the pigment ultramarine, the most expensive of all pigments. In th ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Mayo Clinic
The Mayo Clinic () is a nonprofit American academic medical center focused on integrated health care, education, and research. It employs over 4,500 physicians and scientists, along with another 58,400 administrative and allied health staff, across three major campuses: Rochester, Minnesota; Jacksonville, Florida; and Phoenix/Scottsdale, Arizona. The practice specializes in treating difficult cases through tertiary care and destination medicine. It is home to the top-15 ranked Mayo Clinic Alix School of Medicine in addition to many of the highest regarded residency education programs in the United States. It spends over $660 million a year on research and has more than 3,000 full-time research personnel. William Worrall Mayo settled his family in Rochester in 1864 and opened a sole proprietorship medical practice that evolved under his sons, Will and Charlie Mayo, along with practice partners Stinchfield, Graham, Plummer, Millet, Judd, and Balfour, into Mayo Clini ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Capitation (healthcare)
Capitation is a payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care. The amount of remuneration is based on the average expected health care utilization of that patient, with payment for patients generally varying by age and health status. Types There are differing arrangements in different healthcare systems. Capitation in the USA Primary capitation is a relationship between a managed care organization and primary care physician, in which the physician is paid directly by the organization for those who have selected the physician as their provider. Secondary capitation is a relationship arranged by a managed care organization between a physician and a secondary or specialist provider, such as an X-ray facility or ancillary facility such as a durable medical equipment supplier whose secondary provider is also paid capitation based on that PCP's enrolled ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Health Maintenance Organization
In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities, acting as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. Unlike traditional indemnity insurance, an HMO covers care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider's contracted status. Operation HMOs often require members to select a primary care ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
Integrated Delivery System
An integrated delivery system (IDS), also known as integrated delivery network (IDN), is a health system with a goal of logical integration of the delivery (provision) of health care as opposed to a fragmented system or a disorganized lack of system. The term has sometimes been used in a broad sense with reference to managed care in general (as opposed to fee-for-service care), but in the United States it now more often refers to any specific network of health care organizations constituting a corporate group that attempts to integrate care to some degree (that is, to coordinate the patient journey across care transitions). Some IDSs have an HMO component, while others are a network of physicians only, or of physicians and hospitals. Thus, the term is used broadly to define an organization that provides a continuum of health care services. Background The guiding business model and philosophical goal of the IDN is to serve as a self-contained healthcare ecosystem, with the abil ... [...More Info...] [...Related Items...] OR: [Wikipedia] [Google] [Baidu] |
