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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 medical appropriateness before it is provided, by using evidence-based criteria or guidelines.
Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. [ 1 ] [ 2 ] A discipline-specific process may be referenced accordingly (e.g., physician peer review , nursing peer review ).
The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks.
Reviews in 2008 and 2009 review of research on the effects of health care ratings found that there was evidence that public ratings drove hospitals to improve their performance, but there was limited evidence that they affected how consumers choose health care providers or insurance plans, or that they changed the performance of individual ...
Performance appraisals are most often conducted by an employee's immediate manager or line manager. [3] While extensively practiced, annual performance reviews have also been criticized [4] as providing feedback too infrequently to be useful, and some critics argue that performance reviews in general do more harm than good. It is an element of ...
Health care quality is the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes. [2] Quality of care plays an important role in describing the iron triangle of health care relationships between quality, cost, and accessibility of health care within a community. [3]
The heart of the RIIO system is an MRP, which the British call a "price control". A revenue cap ARM has an RPI - X formula. The typical plan term is 8 years. Since the ARM is based on multiyear cost forecasts, the regulator must carefully review utility business plans.
Pay-for-Performance is a method of employee motivation meant to improve performance in the United States federal government by offering incentives such as salary increases, bonuses, and benefits. It is a similar concept to Merit Pay for public teachers and it follows basic models from Performance-related Pay in the private sector.