Current Trends And Issues In Managed Care

Current Trends and Issues in Managed Care

Managed care aims at minimizing healthcare costs while maintaining the quality of healthcare provision. Healthcare managers and administrators are tasked with implementing strategies that ensure optimal care provision at the lowest cost. In the wake of technological advances in healthcare coupled with the increased use of innovative approaches in healthcare, current practices are aimed at optimizing care provision while reducing the cost. Common features in healthcare, such as provider oversight, provider networks, and prescription tiers, among others, possess some aspects of managed care. Technologies such as electronic health records also increase the efficiency of healthcare provision, thus ensuring optimal care provision at the least possible costs. Accordingly, discussing current trends and issues in managed care is important, emphasizing utilization management and pharmacy benefits management.

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Pharmacy Benefit Management

Danzon, P. (2018). Pharmacy Benefit Management: Are Reporting Requirements Pro- or Anticompetitive?. International Journal Of The Economics Of Business, 22(2), 245-261. https://doi.org/10.1080/13571516.2015.1045741

According to Danzon (2018), the role of PBM is yet to be felt by patients despite its effectiveness in countrywide regulation of pharmaceutical costs. Recent findings reveal that the role of PBMs may be counterproductive as it reflects mainly on the interest of the competitors rather than the consumers, who are the patients.

Drettwan, J., & Kjos, A. (2019). An Ethical Analysis of Pharmacy Benefits Manager (PBM) Practices. Pharmacy, 7(2), 65. https://doi.org/10.3390/pharmacy7020065

The article by Drettwan & Kjos (2019) highlights the role of PBMs in pharmaceutical cost regulations and the issues surrounding their functionalities. According to the author of the article, PBMs have also fallen under scrutiny in the recent past over controversial pharmacy practices. These practices include but are not limited to the prohibition of pharmacists from disclosing to their customers the lower-cost alternative to their medications. This leaves the question as to whether their actions are pro-consumers or pro-competitors.

Summary

Pharmacy Benefit Management (PBM) details the management of prescription drugs on behalf of health insurers, large employers, Medicaid Part D drug plans, and other payers. A pharmacy benefit manager will play a behind-the-scenes role in negotiating drug prices on behalf of insurers. Their role in care provision is thus pivotal in shaping access to medication by individual patients. Pharmacy benefit management functions to regulate the prices of drugs in the country.

Market Forces, Current Trends, And Changes

The respective market forces in the pharmacy benefit management industry include the increasing prevalence of communicable and non-communicable diseases, the willingness of pharmaceutical industries to invest in research for newer agents, the slow adoption of PBMs in developing countries, and market segmentation. The global trend for the PBM market reveals steady growth over the past decades. The market is projected to grow further in the coming decade. Growth has been attributable to the increasing need for life-saving drugs among consumers driving the demand up. The market size is expected to balloon with the increasing prevalence of chronic non-communicable disorders globally. The past decades have seen considerable changes in drug benefit programs. Medicare Part D is a voluntary drug benefit program that benefits persons under the Medicare program.

Utilization Management

Wickizer, T., & Lessler, D. (2018). Utilization Management: Issues, Effects, and Future Prospects. Annual Review Of Public Health, 23(1), 233-254. https://doi.org/10.1146/annurev.publhealth.23.100901.140529

The article by Wickizer & Lessler (2018) describes the process and role of utilization management in healthcare. According to the article, utilization management encompasses all interventions that are done before, during, and after treatment. It seeks to address issues such as the excessive use of services that leads to ultimate wastages without realizing any improvement in the quality of care provision. Utilization management also seeks to address quality issues in healthcare provision, underutilization of healthcare resources and compliance with medical guidelines in care provision.

Konger, R., Ndekwe, P., Jones, G., Schmidt, R., Trey, M., & Baty, E. et al. (2018). Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital. American Journal Of Clinical Pathology, 145(3), 355-364. https://doi.org/10.1093/ajcp/aqv092

The article by Konger et al. (2018) reinforces the functionalities of utilization management in reducing healthcare costs by minimizing unnecessary healthcare procedures. According to the article, reducing unnecessary clinical laboratory investigations and testing via the utilization of an electronic laboratory utilization management system such as the laboratory expert system (LES) effectively reduces healthcare costs without compromising the quality of care provision.

Summary

Utilization management in healthcare evaluates the efficiency, effectiveness, and appropriateness of healthcare operationalization. Utilization management processes encompass all interventions that are done before, during, and after treatment. Utilization management seeks to address issues such as the excessive use of services that leads to ultimate wastages without realizing any improvement in the quality of care provision. Utilization management also seeks to address quality issues in healthcare provision. It also addresses the underutilization of healthcare resources and compliance with medical guidelines in care provision.

Approaches, Techniques and Future

Utilization management utilizes several approaches and techniques. Demand management is a technique under utilization management. Demand management aims at maintaining the efficiency and profitability of healthcare organizations. This, therefore, requires that services or goods produced are commensurate to the demand and not more or less. Utilization review is another technique that requires the healthcare organization to adjust their level of patient care depending on the need. Case management entails tailoring healthcare provision to the patient’s needs or demands. In this case, the healthcare providers will treat each patient as a unique entity with unique care demands.

Approaches to utilization management include focusing on metrics that matter, utilizing the best healthcare resources and the right time, and aligning clinical, financial, and regulatory interests. Focusing on accurate and appropriate healthcare metrics during care provision ensures quality care at the least possible costs. Using the best healthcare resources at the right time also ensures the efficiency of care provision, thus reducing healthcare costs (Bradley, 2022). All these approaches are necessary for cost minimization and quality enhancement of care provision processes.

The future of utilization management approaches remains bright. With technological advances, healthcare facilities will have to adopt healthcare technologies that increase the efficiency and effectiveness of care provision. Currently, there has been a disordered use of healthcare technologies in utilization management. Increasing technological use in healthcare provision may ultimately enhance care efficiency, thus reducing the cost of healthcare. Healthcare facilities will also have to integrate processes and personnel that prioritize innovative healthcare approaches to improve utilization management. Additionally, future utilities of utilization management should be directed towards healthcare quality improvement. Currently, utilization management is majorly used in containing healthcare costs. Future utilities should shift from this functionality towards a more robust role of quality improvement (Wickizer & Lessler, 2018). This will ultimately enhance the overall quality of care provision.

In conclusion, pharmacy benefit management and utilization management remain key concepts in managed care. Their utility in informing cost reductions and quality enhancement in healthcare underpins their relevance in the healthcare enterprise. Pharmacy benefit management informs on the pharmaceutical costs of healthcare. It remains a dynamic field that continues to grow due to several market drivers. Utilization management in healthcare aims at optimizing care outcomes most cost-effectively. In this regard, it employs approaches and techniques that ensure cost reduction while maintaining quality care.

References

Bradley, J. (2022). Four Basic Techniques of Utilization Management. Small Business – Chron.com. Retrieved 22 June 2022, from https://smallbusiness.chron.com/four-basic-techniques-utilization-management-61096.html.

Danzon, P. (2018). Pharmacy Benefit Management: Are Reporting Requirements Pro- or Anticompetitive?. International Journal Of The Economics Of Business, 22(2), 245-261. https://doi.org/10.1080/13571516.2015.1045741

Drettwan, J., & Kjos, A. (2019). An Ethical Analysis of Pharmacy Benefits Manager (PBM) Practices. Pharmacy, 7(2), 65. https://doi.org/10.3390/pharmacy7020065

Wickizer, T., & Lessler, D. (2018). Utilization Management: Issues, Effects, and Future Prospects. Annual Review Of Public Health, 23(1), 233-254. https://doi.org/10.1146/annurev.publhealth.23.100901.140529

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Question

Using the South University Online Library or the Internet, research a series of topics that will help you understand the current issues regarding managed care. You can use keywords such as (but not limited to) managed care, current trends and issues in managed care, pharmacy benefit management, or utilization management. Like many other aspects of health care, managed care is continually changing and evolving to meet current consumer and market demands. This week, you are required to write an essay on the following topics:

Current Trends and Issues in Managed Care

Pharmacy benefit management
Utilization management
Use the following guidelines for developing your essay:

Select at least two articles for each topic from the SUO library, and write a review for each source of information.
Present a summary for each topic, tying together the information learned about that topic.
Describe and evaluate the market forces, current trends, and changes in drug benefit programs over the last fifteen years.
Discuss basic approaches and techniques used in utilization management.
Analyze the future of utilization management approaches. How might they change, and why?
Justify your ideas and responses by using appropriate examples and references from reputable and scholarly texts, websites, and other references.
As in all assignments, cite your sources in your work and provide references for the citations in APA format.

This is a 3–5-page paper completed in APA format that includes an introduction and conclusion.

Please refer to the rubric for this assignment for full understanding of the requirements.

Current Trends and Issues in Managed Care