Utilization Management is Broken. Now is the Time to Rebuild.

Friction…Abrasion. Denial…Appeal. Cost…Cost Center.

None of these words sound positive, do they? Yet they’ve often described utilization management between payers and providers. Denials and appeals became a status quo that costs hundreds of millions of dollars per year, while increasing the discord between payer and provider which often trickles down to the patient. Clinical expertise has slowly become all but cut out of the review process, which was subjective, administrative and tailored to a tool, not tailored to the patient. The costs mount, the tension increases, the system buckles.

In the wake of COVID-19, this status quo should not be allowed to stand. What I’ve seen over the past few months has been heartening: a groundswell of collaboration between providers and payers, new ideas bearing fruit, a realization that the patient is more important than paperwork.

We shouldn’t go back to the way things were. Today, we should set forth to rebuild utilization management through three major steps: restoring clinical reliance, rethinking the administrative process, and reframing payer-provider partnerships.

Restore Clinical Reliance

Utilization management (UM) was intended to be a complex clinical judgment, yet it was not always treated that way: nurses and physicians are now reliant on traditional criteria sets rather than their clinical expertise, which leads both hospitals and health systems to dispute cases based on the criteria, not on the clinical merit of the case. This is changing.

I’ve seen leaders nationwide, from CEOs to CFOs to VPs and directors, take a closer look at utilization management as a clinically-centered value add for their organizations. They realize that they have hired the right nurses and physicians and want to put them “back in the driver’s seat” across the review process: initial determinations, peer-to-peer reviews and beyond. And as we add technology to the mix, we can remove the administrative quicksand that keeps staff from doing their best work. With technology and teams aligned, reshaping what utilization review can achieve – lower costs, appropriate care, optimal outcomes – is within view.

Rethink the Process

Technology has so much to offer healthcare, both by reducing complexity and making it easier to clinicians to work at the top of their license. Correspondingly, forward-thinking leaders now have technologies like artificial intelligence and its subdomains (machine learning, deep learning, natural language processing and the like) in their headlights, bringing them to bear on process automation, risk stratification and more. Until the past few years, UM has not received the same level of attention and innovation as other parts of the continuum. However, that is rapidly changing. There are now solutions tailored to UM-specific needs and activities across the marketplace – and they set a new, positive tone for the profession.

Prominent leaders across the nation have already adopted novel approaches to their utilization management processes, either by adopting technologies that make their staff more efficient, effective and clinically focused or by harnessing automation that can reduce the administrative burden for their staff. I see this trend accelerating rapidly and paving the way for more direct, transparent relationships between payers and providers.

Reframe Payer-Provider Partnerships

As with healthcare at large, utilization management should be centered on the human: patient, member, loved one, friend, partner. Are they the recipient of unintended cost overruns or impacted financially by disputed claims? Payers and providers are both guardians for the people and I view it as our duty as an industry to get patient care right for them; our secondary duty is to reduce the administrative burden and complexity that stifle care delivery and increase costs that get passed along to consumers. As an entrepreneur, my focus is on that second duty.

During the course of the COVID-19 pandemic, several of client organizations – United Health Services, Chesapeake Regional Medical Center, Citizens Medical Center – have adopted the same approach as our client Covenant Health, an integrated health system based in Knoxville, TN, which is using our technology platform to connect them directly with a major national payer for utilization review activities. These hospitals and the payer have cut out the faxing/phone tag/lack of clinical information conundrum by using this platform to escalate cases directly to the payer, who then can undertake real-time case reviews and approvals for members as well as view the admit and discharge info that has been invaluable during the pandemic. To quote a leader at the payer, “the days of having adversarial relationships between payers and providers has got to end.” By rethinking and rebuilding what utilization review should be, these hospitals are leading a charge that will reshape payer-provider relations.

Rebuilding, Together

As the move towards value-based, human-centered care accelerates, provider-payer trust must increase. Utilization review that is clinically centered, technology-driven and collaborative acts as a bridge of trust between payer and provider. With objectivity in the process, results can be quantified, outcomes can be tailored, and relationships can be mended.

As a healthcare leader, I ask you to find a new way forward for your people, processes, and partnerships, within utilization management and without.

Together, we can build a smarter future for healthcare.

This article originally appeared in the July 2020 edition of Collaborative Case Management (published June 25), a publication of the American Case Management Association. The original article can be found here (page 37).