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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 [1] Committee on Utilization Management by Third Parties (1989; IOM is now the National ...
The most common managed care financial arrangement, capitation, places healthcare providers in the role of micro-health insurers, assuming the responsibility for managing the unknown future health care costs of their patients. Small insurers, like individual consumers, tend to have annual costs that fluctuate far more than larger insurers.
Contract lifecycle management (CLM) is the proactive, methodical management of a contract from initiation through award, compliance and renewal. Implementing CLM can lead to significant improvements in cost savings and efficiency. [ 1 ]
Value-based health care (VBHC) is a framework for restructuring health care systems with the overarching goal of value for patients, with value defined as health outcomes per unit of costs. [1] The concept was introduced in 2006 by Michael Porter and Elizabeth Olmsted Teisberg , though implementation efforts on aspects of value-based care began ...
Contract management or contract administration is the management of contracts made with customers, vendors, partners, or employees.Contract management includes negotiating the terms and conditions in contracts and ensuring compliance with the terms and conditions, as well as documenting and agreeing on any changes or amendments that may arise during its implementation or execution.
An additional complication when evaluating cost efficiency in healthcare is the potential tradeoff with the quality of healthcare. The researchers Paul L.E. Greico and Ryan C. McDevitt argue that policies aiming to improve cost efficiency through incentivizing hospitals to reduce costs may inadvertently affect health outcomes or the quality of ...
Providers may bear all of the savings and/or excess costs (100% risk), or they may bear a fraction of the risk while payers continue to bear the rest. Exclusions, tail risk, and stop-loss criteria: Bundled payment models may choose to set up a variety of safeguards that limit the financial risk that providers bear under extreme circumstances.
The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of healthcare databases and related software tools and products from the United States that is developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ).