There’s a changing philosophy in health utilization management today, away from simply thinking of it as a cost-containment approach and more toward using it as a proactive tool to achieve the oft-repeated mantra of the right care for the right patient at the right time. Data and automation are increasingly being used to make that shift possible, while also putting greater power in providers’ hands to make medical decisions.
As we look to 2017, here’s what three top industry leaders see as the top trends, challenges and opportunities facing health utilization management in the coming year:
Diane Smeltzer, VP of Clinical Programs, Anthem, Inc.:
“[The trend is] really about provider enablement. The best person to be managing a patient’s care is their provider. That’s who the patient will respond best to. … We are looking at transitioning some of the work we traditionally would do to what we envision our provider partners doing in the future, [including] utilization management. … We help from the data and analytics standpoint in terms of doing continual analysis; for instance, what do we do prior authorizations on and why? … We may say, there’s something going on with this particular surgery or procedure because we deny it a lot. How can we work with our providers to ensure they are giving us the correct information the first time around? There’s a lot of information we can provide to them, and help them use that data to better care for patients.
“Another big opportunity is around technology. We are trying to move toward more automation around utilization management. We have an opportunity and challenge in that we are putting in place tools for providers to utilize, starting with an interface on our provider portal where providers can enter information and request a PA without having to talk to anyone. it’s more efficient for them and for us.
“The second part is that we are automating some of the decision-making. We can take requests for certain prior authorizations and code them into the system with algorithms so that as the provider answers the questions, they get approval without having to talk to anyone in our organization…. It’s about being easy to do business with and putting the care of the patient in the provider’s hands.”
Caroline Carney, M.D., Chief Medical Officer, Magellan Health:
“The first area under consideration is the effect of parity on utilization management programs. At Magellan, we embrace parity and want to ensure all patients are treated equally regardless of their desire to pursue behavioral health or medical treatment. All of our utilization management programs have been under review to meet parity guidelines. … We review all cases individually to be sure that the care being given is individualized.
“[The trend is] a shift away from traditional utilization management, looking at it as only a tool to control costs or control unneeded care, and more toward developing the right networks and case management for those who need it. … Instead of putting utilization management in front of all services for all providers. there are better ways of doing quality checks on the back end and looking at metrics that would suggest that the member is either being over treated or inappropriately treated. I think you will see a shift in that direction across the country.
“The greatest challenge is lack of full and timely data. Many states allow filing limits up to a year for providers that are on paper claims. The greatest opportunity is the flip side, looking at the amount of data we can potentially have that would guide and direct best practices, and in the right hands help us understand at a population level and an individual level what the quality of behavioral healthcare can look like in the future. That’s tremendously exciting.”
George Furlong, URAC Board Member representing the American Association of Preferred Provider Organizations (AAPPO); SVP, Sedgwick Claims Management Services, Inc.:
“Employers, carriers and state regulatory agencies are paying more attention to the possible overuse and disruption to medical care delivery of UR services. Additionally, there has been talk in certain jurisdictions about separating URO’s from the payer. While this could certainly benefit the system, those entities that overuse these services should be the target. A good URO will evaluate and understand how best to manage treatment plans in compliance with evidence based medicine without undue delays or overly aggressive denials of care. States should approach the same way. Additionally, state-mandated reporting and turnaround time for authorization could be impacted if URO’s are required to be separate from a payer. The biggest challenge is risk to payers who offer these services by not allowing yet holding them responsible for timely delivery of response to requests for authorization. The biggest opportunity is streamlining the process through data analytics and recognizing top performing doctors.”
The bottom line? All of these trends point to how critical best practices in utilization management will be in the changing healthcare market. Greater cooperation between providers and payers, strategic use of data and a patient-first mentality will guide the role of utilization management in the delivery of value-based care.