UM Cardiovascular Disease in Individuals Discussion Responses

Respond to 2 peers :

Peer# 1

Part 1:

Think about a disease with which you are familiar, and create a list of all the data elements that you think a physician and allied health personnel in a physician’s office would generate for this disease.

Data on 289 patients with Cardiovascular Disease seen at UVA ambulatory clinic in 2022.

Age: Over 50

72%

Body Mass Index (BMI) >30 kg/m2

66%

Male

48%

Female

52%

Previous History of Heart Problems

58%

Family History of Heart Problems

70%

Diabetes

28%

Smoker

9%

History of Smoking

32%

High Blood Pressure

43%

Active – Regular Exercise

57%

High LDL Cholesterol

61%

Recommended Amount of Sleep Per a Night

42%

Needed Surgical Intervention

21%

Died from CD related causes

3%

Part 2: Explain the difference between case management and utilization review. 

When a patient may not understand a medical process, why other providers need to get added into their care, or people cannot agree on the care of someone unable to make their own medical decisions, or perhaps a patient needs to be transferred to another facility, a case manager is assigned to the patient to make sure all laws, regulations, rights, and HIPPA compliants are being met. Occasionally we have a patient in our clinic that needs urgent mental health treatment and we would reach out to psychiatry and case management.

One of the key roles of a hospital case manager is to assess the patient’s health insurance plan and to work with the insurer and multiple medical providers to ensure that the best care is delivered with the least financial burden.

Utilization review (UR) is the function or department that ensures appropriate, efficient, and effective health care for patients (Davis, 2023, p. 90).  A hospital’s utilization review department reviews patient care once a patient is admitted.   The process should result in high-quality care administered as economically as possible and in accordance with current evidence-based care guidelines. They review the plan of care for the patient, assess if the test/procedures/ length of stay fit the illness/disease of the patient.  Say a patient is seen for a heart attack, why are the doctors ordering x-rays for a broken toe.  A UR department would reach out to the ordering physician for the medical reasoning.  The UR department can assess if someone truly needs to be in ICU or if a step down unit is appropriate, again they have conversations with the patients physicians asking why, and a couple reasons that they do this is to make sure that the higher charge for an ICU room is necessary, and they try to keep the inpatient bed flow going smoothly.  The UR department will also verify patient’s insurance coverage and UR staff may be involved in discharge planning.

The government requires hospitals to have an effective utilization review program in order to participate in Medicare and Medicaid.1 And there are also drug utilization review protocols in place for both Medicare2 and Medicaid,3 in an effort to reduce abuse and misuse of certain medications, particularly opioids.

Peer# 2

Part 1:

Think about a disease with which you are familiar, and create a list of all the data elements that you think a physician and allied health personnel in a physician’s office would generate for this disease.

Data on 187 of the Patients Diagnosed with Melanoma at Forefront Dermatology in 2022

Age (50+)

78.00%

Excessive Environmental Exposure

84.00%

Family History of Melanoma

32.00%

Tanning Bed Usage

67.00%

Fitzpatrick Scale (Skin Types 1&2)

92.00%

History of Chronic Immunosuppression

28.00%

Cancer History

35.00%

Parkinson’s History

15.00%

No Sunscreen Use

83.00%

Part 2: Explain the difference between case management and utilization review. 

    Case Management is the process when a professional helps a patient develop a simpler plan than supports the patients needs, whether that be help with a complicated diagnosis or a financially distressing situation. These professionals pave a pathway for patients to have a straight forward plan in regards to their diagnoses. A patient whos been diagnosed with Stage 4 Colon Cancer will have a Case Manager assigned to them to make sure the patient is getting the adequate care needed to prevent further deterioration of the patients health. 

   Utilization Review is practiced before, during, and after a patient is treated. This is a major unit of cost management in health care. Utilization Review is more focused on the financial aspect of the patients encounters, rather than the personal aspect. Imagine a patient with 75% BSA of Plaque Psoriasis. The provider wants to start the patient on a Biologic, Stelara, due to the patient having no improvement with topical treatment. The provider would send in a prescription for the drug, which would likely result in the need of a Prior Authorization which is a step in the Utilization Process. If the PA would be denied, then an appeal would be required, which is another step into the utilization process.