Utilization management
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Utilization management (UM) is defined as "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".[1] Utilization review is synonymous with, or a part of, utilization management (depending on how the terms are used).
UM is the evaluation of the appropriateness and medical necessity of health care services, procedures, and facilities according to evidence-based criteria or guidelines, and under the provisions of an applicable health insurance plan. Typically, UM addresses new clinical activities or inpatient admissions based on the analysis of a case but may relate to the ongoing provision of care, especially in an inpatient setting.
A UM program comprises a range of procedures, reviews, roles, policies, and processes, including:
- Proactive procedures such as discharge planning, concurrent planning, pre-certification and clinical case appeals.
- Concurrent clinical reviews, peer reviews as well as appeals introduced by the provider, payer or patient.
- Roles such as UM Reviewers (often an RN with UM training), a UM program manager, and a Physician Adviser.
- Policies regarding the frequency of reviews, priorities, and balance of internal and external responsibilities.
- Processes for escalation processes when a clinician and the UM reviewer are unable to resolve a case, dispute resolutions for allow patients, caregivers, or patient advocates to challenge a point of care decision, and for evaluating inter-rater reliability amongst UM reviewers.
UM Criteria may be developed in-house, acquired from a UM vendor, or acquired and adapted to suit local conditions. Two commonly used UM criteria frameworks are the McKesson InterQual criteria,[2] and the Milliman Care Guidelines (Milliman is now known as MCG).
Prospective Review
Similar to the Donabedian healthcare quality assurance model, UM may be done prospectively, retrospectively, or concurrently.[3]
A prospective review is typically used as a method of reducing medically unnecessary admissions or procedures by denying cases that do not meet criteria or allocating them to more appropriate care settings before the act.
Concurrent Review
Concurrent review is carried out during and as part of the clinical workflow and supports point of care decisions. The focus of concurrent UM tends to be on reducing denials and placing the patient at a medically appropriate point of care.[4] Concurrent review may include a case-management function that includes coordinating and planning for a safe discharge or transition to the next level of care.
Retrospective Review
A retrospective review considers whether an appropriate level of care applied after it was administered. The retrospective review will typically look at whether the procedure, location, and timing were appropriate according to the criteria. This form of review typically relates to payment or reimbursement according to a medical plan or medical insurance provision. Denial of the claim could relate to payment to the provider or reimbursement to the plan member.
Alternatively, a retrospective review may reflect a decision as to the ongoing point of care. This may entail justification according to the UM criteria and plan to leave a patient at the previous (current) point of care or to shift the patient to a higher or lower point of care that would match the UM criteria. For example, an inpatient case situated in a telemetry bed (high cost) may be evaluated on a subsequent day of stay as no longer meeting the criteria for a telemetry bed. This may be due to changes in acuity, patient response, or diagnosis, or may be due to different UM criteria set for each continued day of stay. At this time the reviewer may indicate alternatives such as a test to determine alternate criteria for continued stay at that level, transfer to a lower (or higher) point of care, or discharge to outpatient care.
Criticism
UM has been criticized for treating the cost of care as an outcome metric. This confuses the objectives of healthcare and potentially reduces healthcare value by mixing up processes of care with results of care.[5]
Some authors have pointed out that when cost-cutting by insurers is the focus of UM criteria, it may lead to overzealous prospective denial of care as well as retrospective denial of payment. As a result, there may be delays in care or unexpected financial risks to patients.[5]
See also
References
- ^ Institute of Medicine (1989), Controlling Costs and Changing Patient Care?: The Role of Utilization Management, Washington, DC, USA: National Academies Press, doi:10.17226/1359.
- ^ Mitus, A. J. (2008). The birth of InterQual: evidence-based decision support criteria that helped change healthcare. Prof Case Manag, 13(4), 228-233
- ^ Donabedian, Avedis (2003). An introduction to quality assurance in health care. Oxford University Press. pp. 92–93. ISBN 9780195158090.
- ^ O. Olakunle, B. Iskla, and K. Williams, "Concurrent Utilization Review: Getting It Right," The Physician Executive Journal, Vols. May–June, pp. 50-54, 2011
- ^ a b Porter, M. E. (2010). What is value in health care? New England Journal of Medicine, 363(26), 2477-2481.