Imagine an altogether different kind of utilization management that both payers and providers appreciate, where approvals are made at the point of decision, not after the fact. Utilization management as we know it is flawed. But keeping some semblance of the old model is necessary and a smart way to move forward.
The old (i.e. current) UM model puts providers and payers at odds with each other, with providers resenting after-the-fact decisions, and payers uncomfortably perceived as the guardians of cost containment. That adversarial, even abrasive relationship simply has no place in the shared risk reimbursement models of the future.
What's more, the old UM model is painfully manual, generating billions in administrative costs. It lacks transparency among the various healthcare stakeholders, and most egregiously, it focuses on every single interaction, not the exceptions that matter the most.
New, diverse risk and payment models bring a renewed emphasis on strong utilization management capabilities. The pressure to reduce operating costs and improve care demands that UM become automated, intelligent, efficient, and effective. We propose a new model in which communication happens at the point of decision, through the use of contemporary cloud-based healthcare technology.
Our proposed model drives communication via a shared healthcare cloud that aligns all stakeholders at the point of decision. Rather than the current laborious manual process of authorization, the system digitally queries the clinical record, with appropriate care decisions garnering immediate approval.
Some would be pended for targeted medical review based on utilization patterns. The remaining decisions that didn't meet evidence, but still might be considered appropriate, would go through a manual review with the payer. Automation of approvals are based on how well a provider's practice patterns align with evidence-based practices.
This model can provide useful analytics to help focus on those cases that truly require manual intervention. Payers can dial-up or dial-down the care events that need an authorization. The data collected becomes a core driver in the evolution of the model, allowing payers to zero in on areas that are driving adverse outcomes and significant variation in spend.
Moreover, the automation facilitates the approval of requests that are aligned with quality and cost objectives and identifies outliers. This in turn helps the plan to target interventions and improve decision making.
Providers will benefit by reducing their burden and focusing on the cases that need them. They will only be required to submit a simple, automated notification, avoiding a significant number of lengthy medical reviews for authorizations. The more a provider practices in line with evidence-based medicine, the fewer authorizations are needed, the lower the administrative burden, and the more immediate the approval. This can power new shared savings and value-based reimbursement models based on quality and outcomes as well.
How do we get there? The first step is an investment in automation to capitalize on clinical and business rules that eliminate the need to handle many of the preauthorization requests received today. Many of the tools exist today across the various stakeholders, but it is the connectivity layer that makes this model possible in a variety of configurations and drives value.
The next step is connecting the clinical rules for medical necessity to the EMR, automatically retrieving the information needed to support a medical review. This integration in the provider EMR further eliminates burden by accessing the clinical record directly and automatically submitting the necessary clinical data for authorization. Clinical and business rules can be applied and authorizations automatically approved when rules are met for that provider.
Finally, as the teams work and improve, there will be a need to analyze performance and determine where the right manual interventions should occur, to improve the quality and efficiency of the process.
If we don't move to a more efficient and technologically appropriate model such as this one, administrative spend and management of inappropriate medical costs will continue to pose challenges for health plans and providers alike. In addition, we will lack the ability to truly understand the targeted areas where preauthorization makes the most sense.
Let's get to a world where payers and providers can collaboratively measure, manage, and refine high-quality care delivery, while reducing medical and administrative costs--and do so with a common shared vision that balances all stakeholders' concerns.
Matthew Zubiller is vice president and general manager of strategic growth and innovation and Tammie Phillips is vice president of business consulting at McKesson Health Solutions.