Controlling Costs and Changing Patient Care? The Role of Utilization Management (1989) / Chapter Skim
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Conclusions and Recommendations
Conclusions and Recommendations
Pages 143-162
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From page 143... ...
Although attempts to manage the use of health services on a prospective case-by-case basis are not inventions of the 1980s, the application of utilization management techniques in private health benefit plans has become widespread only during the last half-dozen years. Its growth reflects purchasers' dismay over continuing rapid rises in health care costs and their perception that much care is unnecessary.
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From page 144... ...
prior review of the appropriateness of proposed medical services and (2) high-cost case management.
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From page 145... ...
Third, utilization management in the private sector operates under few explicit regulatory restrictions. There is, however, considerable awareness among review organizations and major purchasers of the legal risks inherent in efforts to influence patient care decisions and operationalize the terms of health benefit plans.
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From page 146... ...
when complaints about utilization management programs stemmed specifically from private programs rather than Medicare, Medicaid, or internal hospital programs or (2) when they really involved prior review or case management rather than basic exclusions in benefit plans, retrospective claims denials, or provider payment methodologies.
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From page 147... ...
the delineation of review criteria based on clinical evidence and practice guidelines. The research on feedback and education strategies to influence physician decisions on patient care suggests that the criteria used to make medical necessity assessments will be more likely to win acceptance and change behavior if they are based on good clinical evidence from respected academic and professional sources and if the medical community is involved in the process of criteria development.
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From page 148... ...
In addition, some moves are being made that may standardize certain aspects of utilization management and reduce the variability and ambiguity now complained of by both purchasers and providers of care. One example, described in Chapter 4, is the effort initiated by the American Medical Association, the Health Insurance Association of America, and the Blue Cross and Blue Shield Association to develop guidelines for the conduct of prior review programs.
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From page 149... ...
ISSUES FOR THE FUTURE In Chapters 3, 4, and 5, the committee identified some shortcomings in utilization management or gaps in our knowledge that raise concerns about patient protection, particularly given the course now being charted by purchasers and utilization management organizations. If the positive potential of utilization management is to be encouraged, then the committee believes that several issues need attention.
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From page 150... ...
Responsibilities of Employers and Purchasers As financers of both utilization management and health services, employers are in the best position to exert influence on the conduct of prior review and high-cost case management programs. They have a direct interest in programs that work fairly and effectively to ensure the value of their investment in employee health benefits.
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From page 151... ...
As prudent managers of a total program of health benefits, employers should also examine other aspects of their benefit plans for impediments to the appropriate use of medical services or the rational payment for these services. For example, if reviewers are judging hospitalization to be unnecessary for intravenous (IV)
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From page 152... ...
Ratio to covered individuals 4. Clinical criteria for assessing medical services a.
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From page 153... ...
Harm includes discouraging appropriate care and mishandling confidential information. When organizations perform prior review and high-cost case management for individually purchased insurance plans (with no employer sponsorship)
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From page 154... ...
However, the cooperative efforts of organizations like the American Medical Association, American Hospital Association, Blue Cross and Blue Shield Association, and Health Insurance Association of America to develop guidelines for review are encouraging. The committee is aware that further steps, particularly making clinical criteria available, raise difficulties given the competitive environment of benefit plan administration.
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From page 155... ...
With respect to third-party payment, the committee agreed that health care practitioners and institutions are responsible for · cooperating with payers' reasonable efforts, including utilization management, to assure that they are paying for appropriate care within the terms of their benefit plans, but · constructively challenging unreasonable review programs and specific decisions that threaten patient safety or damage patient privacy. Although some difficult situations with insurers and review organizations may be more conveniently and quickly dealt with in the short term by misrepresenting patient symptoms, diagnoses, or treatments, the committee believes it is in the patient's, physician's, and society's interest over the long term for physicians to deal honestly with reviewers and claims administrators and to challenge questionable criteria, procedures, and decisions Erectly.
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From page 156... ...
In the context of this committee's consideration of appropriate medical practice, an obvious responsibility for health care practitioners is to stay current with scientific literature on the necessity and effectiveness of medical services in their area of practice. (Many researchers would add that practicing physicians should, if at all possible, participate in the clinical trials and other research on which this literature rests.)
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From page 157... ...
However, even if some of the techniques now employed by utilization management organizations are abandoned or the organizations themselves change, improvements in the criteria for judging appropriate care and for monitoring the provision of care will continue to be relevant. The longer-term recommendations of the committee focus on the foundations for such judgments: knowledge development, knowledge application, and value clarification.
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From page 158... ...
It is expensive, methodologically troublesome, and slow to pay off. As part of the overall strategy for containing total health care costs and improving the appropriateness of health care for all citizens, the committee urges federal and private consideration of carefully targeted research
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From page 159... ...
The two latter approaches have provided the bases for explicit and implicit review criteria used in utilization management organizations, but review organizations appear to have made little use of explicit clinical protocols. The committee has cited analyses that show that some practice guidelines do not match relevant empirical research very well, and the fit between practice guidelines and criteria for utilization management may likewise be poor.
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From page 160... ...
The protections offered by caveat emptor, self-regulation, and tort liability, although important, do not respond to all concerns about the impact of utilization management on patients, providers, and overall health care costs. Moreover, the current lack of oversight poses some risks to utilization management as a promising strategy for managing benefit costs.
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From page 161... ...
And if utilization management is helpful, how can provider payment methods, retrospective utilization review and feedback techniques, resource planning mechanisms, and other tools be used to reinforce utilization management and deal with problems such as distorted payment rates or excessive use of low-cost, high-volume services not effectively addressed by utilization practice. And as noted in Chapter 3, proposed state regulations vary enormously and, in some cases, could make prior review and highest case management infeasible.
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From page 162... ...
This report has provided initial views on some of these questions. The Institute of Medicine will continue its efforts to better define what role utilization management might play in helping society find an acceptable balance of efficiency, access, and appropriateness in health care.
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