QUIZ 2: UTILIZATION MANAGEMENT: AN EVOLVING APPROACH TO MANAGING CARE

OVERVIEW 9: MANAGING THE UTILIZATION

OF HEALTH CARE SERVICES:

HSA 312 SPRING 2021

OVERVIEW OF UTILIZATION MANAGEMENT

UTILIZATION MANAGEMENT THROUGH 2000

A. MANAGING CARE: RELYING ON PROVIDER JUDGEMENTS AND DEFINITIONS OF QUALITY AND APPROPRIATENESS OF CARE IS NOT ENOUGH.

EVOLVING APPROACHES TO EVALUATING UTILIZATION AND QUALITY OF SERVICES:

1. Leave quality and clinical decision-making to the providers: HANDS OFF - (Indemnity and Service Health Insurance Plans).

2. Quality and clinical decisions should be subject to common agreement by clinical providers, insurers, and employers working together: COLLABORATIVE AGREEMENT ON IMPLEMENTATON OF TRANSPARENT STANDARDS OF QUALITY AND APPROPRIATE UTILIZATION - (Kaiser Permanente Health Insurance Plans and Networks).

3. Questions about the scientific nature of clinical decisions have grown substantially in the past 25 years: Viewpoint #2. has become more prevalent since 2000, with significant buy-in from large Integrated Delivery Systems.

A.1. DEFINITIONS OF MANAGED HEALTH CARE: WHERE DOES UTILIZATION MANAGEMENT FIT IN?

Implementing a variety of techniques for Managing Personal Health Care Goods and Services: Tools and Programs for Influencing the treatment decisions of Patients/Plan Enrollees, and for influencing the treatment, pricing, and other clinical utilization decisions of Providers (hospitals, integrated delivery systems, physicians, physician groups).

B. UTILIZATION MANAGEMENT: ITS ROLE IN MANAGING HEALTH CARE

1. What is it and Who does it?

· A set of activities led and executed by Physicians, Nurses, and selected non clinical providers which are meant to influence the behavior of health services providers, health insurance plan enrollees, and/or patients who regularly receive the bulk of their medical care from a particular health care provider (including Physicians, Hospitals, and Integrated Delivery Systems.)

· Utilization Management originated with prepaid health services organizations (PHSPs) like Kaiser Permanente in the decades prior to the 1970s, and originally focused on Utilization Review, Large Case Management, and wellness-oriented and prevention-oriented Demand Management activities. Prior to the 1970s, it was a tool for improving the clinical quality and cost-efficiency with which Personal Health Care Goods and Services were provided to members/enrollees of Managed Health Insurance Plans.

· Before the 1970s, Utilization Management was not used by the Indemnity/Service Health Insurance Plans which dominated the employer-based group health insurance markets until the full transition of U.S. health insurance in the 1990s.

The philosophy of those health insurance plans had been to avoid intervention in clinical provider decisions about the location, level, type and length of treatment provided to health plan enrollees receiving clinical services – so they did not pursue Utilization Management.

· After the 1970s, and facing relentless year to year increases in National Health Expenditures, Indemnity/Service Plans selectively adopted some aspects of the Utilization Management practices of HMOs and other Managed Health Insurance plans. However, they failed in their attempts to slow the growth of National Health Expenditures.

· With the complete shift of employer-based group health insurance to Managed Health Insurance Plans (HMOs, Point of Service Plans, and Preferred Provider Organizations) in the 1990s, Utilization Management was conducted by the vast majority of health insurance plans, and most intensively by HMOs and POS plans. PPOs conducted UM, but in a less intense and intrusive way.

· Utilization Management was conducted by centralized clinical staff (led by physicians, performed by nurses, with assistance from social workers and other personnel as needed).

· In HMOs and POS plans, especially in the 1990s, and less so after 2000, centralized Utilization Management activity was supported and supplemented by Primary Care Practitioners, either acting as “gatekeepers” for their panels of patients, or communicating with the centralized health plan Utilization Management staff.

· After 2000, with the rise of Integrated Delivery Systems of providers as major actors in the U.S. Health Care Delivery System, Utilization Management was implemented not just by health insurance plans, but became central to the internal quality and utilization efforts of those Integrated Delivery Systems. In some systems, such as the Montefiore system, dedicated internal clinical organizations (CMO – Care Management Organization) organized and conducted UM activities.

· Utilization Management evolved after 2000, retaining older methods for influencing provider, plan member, and patient behavior, but also developing additional methods and tools, and relying on the increasingly sophisticated targeting of UM efforts through the analysis of large clinical and insurance plan databases.

2. Purposes of Utilization Management: To Promote Plan Enrollee and Patient Health Status.

· To influence Provider Behavior (Physicians, Hospitals, Integrated Delivery Systems, Home Health Agencies, Rehabilitation Facilities) to encourage the delivery of Effective (Well-Coordinated), Necessary, High Quality, Reasonably Priced Health Care.

Specifically - To make sure that Personal Health Care Goods and Services:

· Are delivered at the right level of care.

· Are appropriate: Necessary, effective, not duplicative, etc.

· Are not, in the case of hospital stays or chronic care facility stays, excessively long.

· Are reasonably priced.

· Are properly and effectively coordinated when care is provided by multiple providers, and/or at multiple site types and locations (hospitals, home health agencies, chronic care facilities, community-based Primary Care Practitioners, for example.)

· To influence Health Insurance Plan Enrollee and Patient Behavior –

· To actively collaborate with Providers to achieve the purposes indicated above, to the extent reasonable and feasible given the physical and mental status of the Enrollee/Patient.

· To actively pursue wellness through exercise, proper nutrition, routine appropriate preventive screening, and other pertinent wellness and preventive care activities.

3. UTILIZATION MANAGEMENT: PRECONDITIONS FOR SUCCESSFUL UTILIZATION MANAGEMENT.

· Use of Payment Systems which encourage the desired behavior.

· Having provider buy-in for the clinical standards used, and the nature, significance, and relevance of identified Utilization Management problems.

· Being able to support your Utilization Management Strategy with reliable data, and convincing assumptions about the nature of the problems being addressed and the related role of providers.

C. UTILIZATION MANAGEMENT: OVERVIEW OF KEY COMPONENTS AND FOCUS BEFORE 2000.

1. Acute focus – Approving or disapproving utilization of services when proposed by clinicians. Focus was on UM decisions at the moment of request, in the course of an institutional stay (hospitals, chronic care facilities), or when faced (Large Case Management) with a Patient already suffering from a major clinical condition or conditions.

Identifying likely or actual inappropriate utilization through the long-term prospective analysis of large clinical and health insurance databases played a small role in Utilization Management during this period.

2. Focus on Traditional Utilization Review: Prospective, Concurrent, Retrospective (usually played a smaller role).

· Prospective determinations about hospital admissions; preauthorization of selected diagnostic imaging procedures and other tests, referrals for some Specialty Physician Consults; preauthorization of elective outpatient procedures and surgeries.

· Use of InterQual Clinical Standards and Milliman Care Guidelines, with local adaptations, to make these decisions.

· Choice of types of care to be subject to Utilization Review:

Does not routinely rely on a structured, data-driven, explicit process of analysis and discussion to choose objects of Utilization Review.

Utilization Review is sometimes focused on high levels of utilization as determined by very generic utilization numbers for members of a specific health insurance plan: See below.

· Concurrent review of inpatient hospital stays: level of care, length of stay, appropriate date of discharge, appropriate next level of care after discharge.

· Use of InterQual Clinical Standards and Milliman Care Guidelines, with local adaptations, to make these decisions.

3. Focus on Demand Management: Promoting central health plan programs and working through Primary Care Practitioners (especially in HMOs and POS Plans) to actively pursue wellness through exercise, proper nutrition, routine appropriate preventive screening, and other pertinent wellness and preventive care activities.

4. Focus on Large Case Management: Combined the practices and technologies used by leading medical authorities with the expertise of specially trained nurse Case Managers who worked. directly with patients and their doctors. Emphasis on care coordination across multiple clinical providers and multiple provider sites. Also focus on arrangements for support services, community resources, transportation.

· Focus on early identification of people with acute catastrophic conditions, often with known

high costs or know diagnoses that lead to high cost in the near term. (Major cardiac events, strokes, high trauma levels due to car accident, for instance.

· Emphasis on single patients.

· Acuity level of these cases is very high.

· Focus on time frames of 60-90 days.

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SUMMARY OF UTILIZATION MANAGEMENT TOPICS AND READINGS

UTILIZATION MANAGEMENT PART 1: REQUIRED READINGS FOR THE WEEK OF APRIL 199, 2021 – READ ALL OF OVERVIEW 9.

VIDEO 1.A. AND READING 1., INCLUDING SAMPLE U.M. PLAN AND TEXT BOX.

ALSO READING 2. FACT SHEET, AND

READING 3, STANDARD UM MEASURES.

· ORIGINS; ACUTE CARE FOCUS; REACTIVE NATURE OF EARLIER FORMS OF UM,

ESPECIALLY UTILIZATION REVIEW.

· BASIC TYPES OF UTILIZATION MANAGEMENT: UTILIZATION REVIEW, DEMAND MANAGEMENT, BIG CASE MANAGEMENT.

· FOCUS OF UTILIZATION MANAGEMENT ACTIVITIES: PRE 2000

· BASICS OF CLASSIC UTILIZATION REVIEW (INPATIENT AND OUTPATIENT.)

READING 7 TEXT BOX.

Common UM Metrics for Program Evaluation

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•Per Thousand Members Per Year (PTMPY) Medical/BehavioralServices

–InpatientAdmissions

–InpatientDays

–SNFAdmissions

–SNF InpatientDays

–Home HealthVisits

–ERvisits

–OPvisits

•PharmacyUtilization

–Generic prescriptionrate

–Adherence rates as measured by timelyrefills

•Other Metrics Per Member Per Month (PMPM) or Per Year (PMPY)

–PCPvisits

–SpecialtyReferrals

–High cost imaging studies (MRI, PETscans)

–Costs per episode ofcare