Utilization Management in Healthcare Services

Utilization Management

Utilization management plays a great role in ensuring efficiency in healthcare services through evaluation of healthcare appropriateness and medical necessity. All healthcare organizations are expected to conduct utilization review through clinical sound procedures, which respect the patient’s rights and having reasonable guideline to follow. Utilization management priority is to offer reasonable support to the patients and ensure that they are getting best services and support from healthcare organizations (Research and markets adds report, 2010).

CVS Caremark, which is also referred to as CVS Health is a popular healthcare organization that has featured in the many lists of best health care organizations.CVS Caremark is a private healthcare organization dedicated to provide best healthcare services through improving health care quality (Evaluation of Medical Specialty Medications, 2014). CVS, which stands for “Convenience, Value, and Service”, reflect organizational intension to ensure clients satisfaction in the services offered by the organization.  The organization was certified by NCQA for being compliant to the requirement of Utilization Management. However, there is a great task ahead of sustaining the momentum and ensuring better medication is provided to the patients. NCQA is a body that accredits and certifies a great number of healthcare organizations. The organization is a market leader in specialty pharmacy, Medicare Part D Prescription Drug Plans, and retail clinics. The organization has invested in processes, systems, and personnel in order to be able to achieve effective Utilization management plan.

Organizations Utilization Management Plan

Utilization management program in CVS Caremark is designed to encourage and ensure appropriate use of medication, provide necessary identification to optimal drug use, and encourage cost-effective drug benefit plan design for the patients. The program is supported by evidence-based drug research, guidelines publication, medical practice, and consensus statement. CVS Health collaborated with New Century Health, which is a renowned specialty management enterprise in order to offer clients with better treatment care pathways, evidence-based medicine, quality improvement programs, and peer-to-peer reviews on interactive web based platforms.

The implementation of the plan depends on how effective the organization communicates with key stakeholders including the patients, providers, and payers (Saunier, 2011). Patient communication involves detailed program definition and clear elaboration on how to access their proper medication. There are some technical elements involved in the utilization management plan. This includes retrospective review, concurrent review, preauthorization review, and prospective review.

Retrospective review involves keen analysis of the real utilization data (ITA partners 2010). This includes listing of patients and daily monitoring of their diagnosis, the requested span of stay compared to the actual span of stay, and all other information that helps in managing inpatient processes.

Concurrent review includes detailed screening to ensure medical appropriateness and timeliness required in medical care from the time a patient gets admitted until he/she is discharged (Olaniyan, Brown & Williams, 2011). This review ensures that the order given by doctors to anticipate treatment, monitor patient’s progress, and plan ahead is observed carefully and followed in the most accurate manner.

Preauthorization review involves evaluation of surgeries and other health care services offered by health care organizations. Alternative treatments are considered if available clinical information does not project medical appropriateness.

The weakness in CVS Health Utilization management program is that the intended outcome is not concrete according to the drawn plan because of the high expectations projected in the plan. There is lack of appropriate mechanism and procedure to follow when conducting proper reviews, which determine the success of the plan.


Olaniyan, O., Brown, I. L., & Williams, K. (2011). Concurrent Utilization Review: Getting It Right. Physician Executive37(3), 50-54.

Saunier, B. (2011). The Devil is in the Details: Managed Care and the Unforeseen Costs of Utilization Review as a Cost Containment Mechanism. Issues in Law & Medicine27(1), 21-48.

Evaluation of Medical Specialty Medications: Utilization and Management opportunity. Retrieved (18 Feb 2015) from http://info.cvscaremark.com/insights2014/Singh06-Medical-Specialty-Utilization-and-Management-Opportunities.pdf

ITA partners, inc.; ITA partners receives URAC health utilization management accreditation. (2010). Obesity, Fitness & Wellness Week, 664. Retrieved from http://search.proquest.com/docview/756629368?accountid=1611

Research and markets adds report: Case management: Identifying, monitoring and managing target populations. (2010).Health & Beauty Close – Up, Retrieved from http://search.proquest.com/docview/758024563?accountid=1611