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

READING 8:

DEMAND MANAGEMENT: TWO APPROACHES

INCLUDING THE CONCEPT OF PATIENT DECISION-SHARING IN MEDICAL TREATMENT DECISIONS.

TWO APPROACHES TO DEMAND MANAGEMENT:

More traditional, and more innovative forms of, Demand Management: Focus not just on Preventive Care, Wellness Programs, Nutrition Programs, and Programs oriented toward exercise and other forms of individual and family Self-Care, but also on Patient-Centered Care in which patients are more actively involved in discussing and understanding clinical decisions as part of their routine interaction with clinical providers, such as physicians. ( For example: Patient Decision – sharing.)

1. Demand management is the process of empowering patients to make wiser health care decisions.

It is not necessarily about reducing demand for personal health care services though that may result from the two types of Demand Management outlined below.

· FIRST: One goal of Demand Management is to reduce the need for health care goods and services by improving patients' health status. The emphasis here is on wellness, health promotion, risk reduction, prevention, screening and early detection for individual patients and their families. The goal is to engage patients in the quest for better self-care, better personal health status, and appropriate care as necessary. If that reduces the level of health care service demand, that is a desirable by-product of those activities.

THIS IS THE TRADITIONAL DEMAND MANAGEMENT APPROACH, WHICH PREDOMINATED PRIOR TO 2000, AND IS STILL THE CENTRAL PART OF DEMAND MANAGEMENT IN MANY HEALTH INSURANCE PLANS.

· SECOND: Since 2000 an additional component of Demand Management in some health insurance plans is the implementation of patient-centered Shared Decision-making programs which respect and address patient treatment preferences. (Preference Sensitive conditions.)

This Demand Management strategy attempts to improve patients' decisions about medical treatment for a selected group of medical conditions. Tools such as patient education materials, telephone advice lines, and consultation with specially trained Nurse Consultants can aid the decision-making process by making patients more informed and assertive in their interactions with Physicians. SEE 2. BELOW FOR MORE DETAIL.

2. The implementation of patient-centered Shared Decision-making programs . One of the most discussed aspects of this Demand Management strategy is the greater involvement of patients in decisions about the appropriate treatment for selected high-volume procedures (Patient Decision Sharing).

· Note: Not all medical interventions are appropriate candidates for the kind of intense patient involvement entailed in Patient Decision-Sharing.

· Treatments and Hospital Admissions associated with Preference Sensitive Care are the medical interventions most likely to be the subject of Patient Decision Sharing.

· Preference-sensitive care comprises treatments for conditions where MULTIPLE legitimate treatment options exist: There is more than one treatment option. Choosing among multiple treatment options involves making decisions about significant tradeoffs among different possible outcomes of each treatment. (For example, some people will prefer to accept a small risk of death to improve their function; others won’t).

Examples: Treatment of prostate cancer; treatment of certain types of chronic lower back pain.

· Extensive research by the Dartmouth Atlas of Health has shown that there are major variations by region of the United States in which treatments are given for such conditions. Specifically, after adjusting for patient age, sex, severity of medical condition, and other factors, researchers discovered provider treatment preferences or biases which may indicate that patients do not fully understand the full range of treatment options for a given condition, and may not have a good understanding of the trade-offs involved in choosing one treatment over another.

There is some evidence, though not conclusive, that Patient Decision Sharing in decisions about Preference-sensitive Care can lead to better patient satisfaction and less per capita expenditure without compromising quality of care.

There are several reasons why implementation of targeted Patient Decision Sharing programs by Health Plans, IDS, and single Hospital’s merit consideration as viable tools of Utilization Management.

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