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Utilization Management: How To Reduce Costs Without Denying Care?

Utilization management (UM), care management, control of spiraling costs, care coordination: these are all the words we hear regularly these days with the advent of accountable care and increased enrollment in managed care plans across the country. But how to manage patient care and optimize costs without withholding care? That is the challenge.

To my mind, it cannot be a battle of wills between the primary providers and specialists or providers and patients, nor a question of denying what the patients need for their well-being. It is a matter of a structured approach that eliminates room for error and human vulnerability to increase profit margins. The system has to become financial-proof. By that I do not mean that we should not reduce wastage or do what is needed to reduce costs, but that the primary concern cannot be financial. The primary concern across the board can only be enhanced quality and reduced mortality and morbidity.

How to structure such a program which prevents us from succumbing to greed and ensures that we stay true to our higher selves?

These are some of the elements we need to introduce to a comprehensive care management program, in my opinion:

  1. Structured Approach: A systematic methodical consistent paradigm that touches the patients at multiple points, in an organized manner, reducing chance and catastrophic cases. This structured approach should ensure coordinated care and continuity of care, patient and family engagement, and education utilizing a multi-layered approach to interventions so that patients do not fall through the cracks.
  2. Holistic Approach: Seeing the patient as a social, emotional, mental, and spiritual being and not just a physical entity or a number is critical. Studies have shown that medical interventions can reduce costs by only 10%. An almost 30% impact can be made by social, psychological, and behavioral interventions. A good UM program would have a team of psychologists, counselors, social workers, and behavioral therapists in it. It would also utilize community resources to ensure patient safety and active lives and would also have a focus on proper nutrition, hygiene, and injury prevention.
  3. Continuity of Care: A program of seeing walk-in patients in the primary care providers, preferably the same day with proper triage, would ensure patient satisfaction and reduce emergency room (ER) visits. Seeing one’s provider is always preferable to seeing a new provider in the ER. Ensuring also that hospital discharges are seen within seven days of discharge, as Coleman has pointed out, reduces re-admissions, morbidity, and drug-related complications. A strong hospitalist program along with a SNFist program along with Urgent Care Centers that provide weekend-care and after-hour care augmented by a team of case managers would ensure that communication and care do not break down.
  4. Relationship Management: The best way to optimize costs is to have a great relationship and communication with patients. Trust and credibility are the key. Patients must know that the provider only cares about what is best for them. Once such a relationship is established, educating patients about proper habits, avoiding noxious activities and disease management becomes easy. End of life care can be discussed without any element of antagonism or fear of ‘death squads’. Palliative care and dignity of life can also be focused on along with patients’ rights. A patient who trusts his physician would be able to manage his conditions such as Diabetes Mellitus (DM) or Congestive Heart Failure (CHF) or Coronary Artery Disease well and might be willing to exercise and change habits that are good for him or her. Patients can be educated not to use the ER as the primary source of care.
  5. Claims Review Process: A provider that sees his or her claims expenses regularly is in better touch with patient care as specialist interventions can be reviewed and improved. Part D utilization especially brand drugs can be impacted.
  6. Coordinated Care: One of the most important elements of a Patient-Centered Medical Home (PCMH) is the coordination of care among the primary care providers and specialists and other associated medical staff, such as dieticians, diabetic educators, therapists, etc. Sharing of reports and data with each other and with patients would help significantly in the patients beginning to use the doctor’s office as their medical home.
  7. Optimization of Costs: Being financial proof does not mean indulging in wasteful activities. End-stage cancer patients should not be receiving experimental treatments that do not meet medical necessity. Advanced dementia patients should not be subjected to painful surgery since we are not treating a condition or an organ but the whole patient. What can be done in the office does not need to be done in an ambulatory surgical center (ASC) unless there is a medical reason. What can be done in an ASC does not need to be done in the hospital. Again, medical necessity should always be the overriding concern. Strong evidence-based protocols can also eliminate the fat in the system, e.g., the use of low-molecular heparin for deep vein thrombosis instead of unnecessary admissions, or the use of intravenous Lasix in CHF clinics for patients with stable cardiac function.
  8. Disease Management Programs and Risk Stratification: These can be extremely effective in cases of CHF, DM, Hypertension, etc. Risk stratification is essential to identify the sickest patients and take care of them aggressively and see them every day or every week if necessary. It is the highest risk patients who incur many expenses. They need to have enhanced care and not reduced care, with the use of high-risk clinics, care coordination centers, or team-based care models.
  9. Quality: At all levels or points, the focus can only be on quality, outcomes, patient experience, and compliance. If these are adhered to, the financial returns will take care of themselves. This is my belief and experience. Barwick and Nolan have pointed out that quality-based programs in population-based settings reduce utilization while enhancing health care. Referral processes should be timely and well-documented to ensure no delay in care.
  10. Predictive Preventive Care: Appropriate predictive modeling can be done to stratify medical conditions. Interviews and surveys to reduce falls, control pain, improve bladder function and activity levels can be used along with analytics and artificial intelligence. The use of monitors in-home settings, along with assistive devices, which improve communication can also be used to help those who are at high risk. Bringing in assigned patients pro-actively also serves to catch diseases early and may bring timely interventions. Executive health care clinics can be set up where patients can be given longer appointments with team involvement and more intense education to improve compliance and a more comprehensive review of prior medical conditions.
  11. Population Medicine: Eventually, any good UM program is about the whole population and not just individuals. Group-based interventions or pre-primary care can be used to improve our services to the populace. Community resources can impact care meaningfully and facilitate healthcare improvements that may not be possible on an individual scale.
  12. Provider and Staff Education: Constant training of the provider about the tools available to optimize care, along with training in Locally Covered Determinations and Nationally Covered Determinations and ODAG rules is essential.
  13. Case Management: Case Managers who are subject matter experts enhance care significantly, empower patients, ensure their rights are honored, and help providers scale care. Care coordination centers where licensed nurses, who are skilled in customer service create another level of communication with patients along with e-mails, patient portals, mobile solutions, and discreet use of social media. Discharge dispositions that appropriately assess patients’ needs and abilities can reduce the wasteful use of acute rehab or skilled nursing facilities or home health care.
  14. Contracting: Memoranda of Agreement that is compliant with the Center for Medicare and Medicaid Services can be created to reduce the cost of interventions or devices that are artificially high or to control charge master billing that can be twenty or thirty times Medicare-approved rates. Hospital contracts along with ASCs can be evaluated to control asymmetric payouts.
  15. Certifications: The use of certifications like Patient Safety Organizations or PCMHs creates rigor in processes and induces respect for systems that become independent of subjective or sporadic interventions.
  16. Insourcing: Specialty testing like echocardiograms, pulmonary function tests, Holter monitoring, ultrasounds, arterial and venous dopplers can be done in-house with competent technicians and read by appropriate specialists.
  17. Use of Specialists: Choosing excellent specialists who have fewer complication rates and working closely with them can create economies consistently. Using specialists appropriately at the right time and doing interventions at the right time can reduce complications, morbidity, and the costs and medico-legal complications therein. Use good specialists and make good use of specialists. Discussions or disagreements should be objective, based on facts and standards and not subjective only unless there is a sound basis for one’s judgments.
  18. Patient Empowerment: Patients need to know their rights. They should be able to call the doctor on time and get timely appointments and needed treatments. They should be able to have informed discussions and be able to bring in their perspectives as partners in their health maintenance. They should also know the responsibilities of presenting facts correctly and not concealing their issues out of fear or embarrassment. Every patient should know that they have the right to be heard, treated, helped, and healed. Discussions with patients should be objective, based on standards and for their complete well-being.

These, in a nut-shell are some of the essential elements of a strong UM program. There may be much more to add but, suffice it to say, that an effective UM program is not one based on advanced technology, but on good old-fashioned concern for patients, communication and advocating for them as one’s friends, partners and, sometimes, wards.

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