Business Accent

The Utilities of Utilisation Management

Until knowledge base is expanded and tools and research refined, pre-certification and concurrent review will probably remain as the mainstay of many utilisation management programmes.

The concept of 'utilisation management' (UM) in the context of healthcare delivery is gradually gaining ground. It fundamentally involves review of the necessity for hospital admission prior to admission (pre-certification) and determination of the need for ongoing care (concurrent review). The process can be applied retrospectively also.

Almost every provider or payer-sponsored utilisation management programme includes pre-admission and concurrent review. Typical characteristics of these two components are:

• Collection of data about diagnosis, required services, diagnostic test results, and symptoms.
• Review of criteria that describe the conditions or services to support the care request.
• Comparison of medical information to medical necessity criteria.
• Referral of case to physician review if criteria are not met.
• Physician determination of medical necessity.
• Communication of review outcome.
• Right of physician to appeal decision.

The roles and responsibilities of the attending physician and the party performing utilisation review need to be better defined. To be successful, appropriate and effective, a UM programme should adhere to some reviewable and ever evolving standards. These could be :

• Limit the information collected to the review being performed.
• Promote timely decision making.
• Notify parties of outcome decisions.
• Use explicit criteria to determine medical necessity.
• Provide a mechanism to appeal review decisions.
• Promote the use of appropriately credentialed staff for review activities.

Not only can insurance companies or their contracted utilisation review companies conduct these activities, but also physician organisations and inpatient facilities participating in risk contracts. The scope of services that pre-certification and concurrent reviews apply to may also expand to include outpatient services and free-standing ambulatory surgery centers.

Although pre-certification and concurrent review are the oldest and most developed processes for containing utilisation, their impact on utilisation is unclear. Proponents of these processes contend that they have supported the development of outpatient technology, fostered the shift from inpatient to outpatient care, reduced the number of unnecessary inpatient days and provided a mechanism for timely identification of patients, who require discharge planning and case management.

Critics of the processes complain that they contribute to administrative overheads with an uncertain cost benefit, delay care and are not physician-friendly. The allegations do contain elements of truth. However, well-run programmes result in appropriate admissions and length of stay. Timely review decisions occur using criteria approved by local physicians. Developing and administering these two core processes according to rigorous standards is resource-intensive. They require nurses, information systems, medical review criteria and administrative support.

The need to manage utilisation continues to exist, but health planners and providers recognise that alternative and more effective programmes need to be developed. Techniques such as clinical pathways and disease management are two of the newer approaches to managing utilisation. These two techniques provide information about optimal treatment methods for certain disease conditions, and prescribe treatment methods, medications and visit frequency etc.

Attempts have been made to evaluate programme results for hospital-based utilisation review programmes. It was determined that there was tremendous variance in UM procedures; the ability to determine if these processes provide benefit continues to be hampered as a result of procedural variance. Until the knowledge base is expanded and tools and research are refined, pre-certification and concurrent review will probably remain as the mainstay of many UM programmes. For those organisations that are planning to conduct pre-certification and concurrent review, the following activities are recommended:

Review: Hospitals must focus on pre-certification and concurrent review processes. The processes should emphasise on those procedures that are problematic, pose significant risk, and/or for which there are no clear indications for use. Limiting the number of procedures or services subjected to pre-certification, enhances the cost benefit of the review process. Physicians, who have demonstrated competence in managing inpatient admissions, may even be considered for exemption.

Efficiency: Healthcare organisations must keep the process efficient. For routine cases, where complete information is provided, the case should be certified on the first telephone call. If the case is unable to be certified, the process for completing review should be timely. The organisation conducting the pre-certification process should minimise the use of voice mail or automated attendants.

Support: Hospitals must device strategies to provide support for physicians. The concept of using a physician to determine the need for admission, manage ongoing hospital care and co-ordinate care among multiple providers is gaining popularity. Hospital intensivists have a practice that is devoted entirely to inpatient care. Typically, the primary care provider refers to the rounder or contacts them for advice on how to manage patients.

The development and implementation of guidelines and critical pathways will also provide assistance to primary care providers.

Linkages: Pre-certification and concurrent review must be linked to other medical management programmes. The value of pre-certification and concurrent review can be enhanced by using the results of these processes to support other activities. For example, pre-certification activity can also trigger the case management process. Concurrent review can supply data about quality indicators and determine if cases pass quality screens.

Focus: The practices that delay timely discharge vary from location to location or provider group. A successful programme will identify these practices and then work with providers to modify them.

Implementation: Hospitals can implement an explicit process for managing denials and appeals. TPAs or physician organisations need to pay particular attention to the appeal and denial process. A proposed procedure or service should only be denied after careful consideration of all the facts, consultation with appropriate specialists and examination of treatment alternatives. In addition, the organisation needs to have a process which clearly identifies avenues for appeal to the attending physician and members. The reason for the denial must be clearly communicated in written correspondence shortly after the decision to deny is made.

Dr Vivek Verma
E-mail: drvverma@hotmail.com
The writer is Deputy Medical Superintendent Delhi Heart & Lung Institute New Delhi