Monitoring a patient's prognosis for recovery becomes important in which type of utilization review?

Rationale:

A. Wastage at clinics: While wastage at clinics may contribute to inefficiencies in the healthcare system, it is not a primary reason that cost-control efforts in the United States have not been successful.

B. Global healthcare issues: While global healthcare issues may impact the broader context of healthcare delivery, they are not a specific reason for the lack of success in cost-control efforts within the United States.

C. Poor patient outcomes: Poor patient outcomes may contribute to healthcare costs, but they are not the primary reason that cost-control efforts have not been successful.

D. Cost shifting: Cost shifting refers to the practice of shifting costs from one payer to another, such as from private insurers to public payers like Medicare and Medicaid. This practice can undermine efforts to control costs by redistributing financial burdens rather than addressing underlying cost drivers.

Rationale:

A. Preferred Provider Organization (PPO) plan: PPO plans typically offer members greater flexibility in choosing healthcare providers and may not have as strict requirements for referrals to specialists, reducing barriers to access.

B. Medicare advantage plans: Medicare Advantage plans, also known as Medicare Part C, offer additional benefits beyond traditional Medicare, but they may not exhibit the same issues with access to primary and specialty care as other managed care plans.

C. Medicaid managed care: Medicaid managed care plans vary by state and may have different structures for accessing care, but they often emphasize primary care coordination and may not exhibit the same issues with access as HMO plans.

D. Health Maintenance Organization (HMO) plans: HMO plans typically require members to select a primary care physician (PCP) and obtain referrals from the PCP to see specialists. This structure can create barriers to accessing specialty care, particularly if there are limitations in provider networks or delays in obtaining referrals.