How member advocacy plays a key role in utilization management
The gatekeeper style benefit plans of the nineties, with closed provider panels, arbitrary notification policies and tight preauthorization lists left a bad taste in the mouth of health care consumers. Many of the most problematic features aren’t widely used anymore, but utilization management (UM) programs can’t quite seem to wash out the stain those features left on their reputations.
Houston, we have a PR problem
Too often the media portrays health care coverage decisions as if they’re made by bureaucrats with calculators. Saving money is the only goal, and the patient and health plan are adversaries.
Advocacy-driven UM is the opposite. In this model, UM nurses advocate for members to have timely, evidence-based care in settings that are medically appropriate and cost-effective.
We know that higher health care spending doesn’t guarantee better health outcomes.1 Advocacy-driven UM uses data to help patients get outcome-focused, scientifically sound and financially responsible care. Let’s look at the numbers.
The survey says
A survey2 of over 2,000 physician members of the American Medical Association showed that:
- 65% of respondents believe that 15-30% of medical care isn’t necessary
- If we can eliminate even half of that, we’d save over $105 billion dollars a year
This begs the question, why are physicians prescribing unnecessary care? The same survey sheds light on that too. The top answers were:
- 85% fear of malpractice
- 59% patient pressure or request
- 38% difficulty accessing medical records
Physicians are busy
It’s a fast-paced world and we’re all only human. The average primary care physician has between 1,000 and 4,000 patients in their panel.3 In 2020, the US Food and Drug Administration approved 53 new drugs.4 There were over 400 new treatment guidelines last year. That is a lot of new information for doctors to keep up with and still stay focused on providing the best care possible for patients.
This is where advocacy-driven UM comes in. UM isn’t a barrier to health care. In many cases UM nurses and medical directors help overwhelmed physicians confidently follow established clinical guidelines. They also help members receive care in-line with latest science. Many times, following evidence-based guidelines costs members and plans less. Sometimes it costs more. Either way, advocacy-driven UM nurses prioritize quality and patient outcomes.Ideally, advocacy-driven UM programs are integrated with case management solutions. This integration promotes care in the highest quality care settings, ongoing care coordination and care access support. This seamless transition is critical to avoiding readmissions and putting preventive measures in place for members.
When it’s done right, UM should feel like a great customer service experience to the provider. Reviews are more than a mixture of clinical guidelines, benefit coverage and network access. They represent real health care issues for real people and must be handled with care and attention.
Advocacy-driven UM supplements and supports physicians
Health care providers want what’s best for their patients. They are also highly data driven. This is why, in the advocacy-driven model, we focus on clinical evidence and what’s best for the patient. If there’s a question about what that is, we go looking for more information.
Every provider that submits a request can have a peer-to-peer conversation with a medical director about the case. When the best health outcome for the patient is the end goal for both parties, transparency is a must.
In summary
The best utilization management experience is invisible to the patient. Member advocacy doesn’t just peacefully coexist in this experience. It’s essential to it. There’s collaboration between their health care provider, their health plan and the reviewer. The outcome is a treatment plan that reduces unnecessary services and spending and delivers the right care, at the right time in the right setting.
1 Tikkanen R, Abrams M. U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes? Available at https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019?gclid=EAIaIQobChMIipX81q6l7AIVCa_ICh33aQusEAAYASAAEgILZPD_BwE Accessed September 15, 2021.
2 Lyu H, Xu T, et al. Overtreatment in the United States. PLoS One. September 6, 2017. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5587107/ Accessed April September 15, 2021.
3 Paige NM, Apaydin EA, Goldhaber-Fiebert JD, et al. What is the Optimal Primary Care Panel Size?: A Systematic Review. Ann Intern Med. 2020; 172:195-201. Available at: https://www.acpjournals.org/doi/10.7326/M19-2491 Accessed September 15, 2021.
4 US Food and Drug Administration. New Drug Therapy Approvals 2020. Available at: https://www.fda.gov/drugs/new-drugs-fda-cders-new-molecular-entities-and-new-therapeutic-biological-products/new-drug-therapy-approvals-2020#:~:text=In%202020%2C%20CDER%20approved%2053,Biologics%20License%20Applications%20(BLAs).attention. Accessed September 15, 2021.