Story from the trenches—is utilization review a good thing for healthcare?

 

There is renewed interest in utilization review in workers compensation claims management .  The purpose of utilization review is to provide oversight of professional healthcare decision making.  Utilization review can be viewed as providing reinforcement of the professional decisions rather than to undermine these decisions.  This author does not feel that the goal of utilization review should be to save claims’ cost.  This may be a byproduct of the process, but should never overshadow the ultimate goal of appropriate patient care.

 

UR—negative perspective

Many in the healthcare industry would view utilization review as undermining the autonomy of the healthcare providers as it imposes an external control that may mitigate the individual provider’s healthcare decisions.  The second major objection to utilization review is the amount of time it takes to provide the documentation for medical necessity which increases the cost of the provider’s business.  Those that find this a problem also point to the fact that it takes the clinician away from actual patient care.  Another negative often reported when the discussion centers around utilization review is that the standards and clinical guidelines imposed by the utilization review process fail to take into account those individuals who fall outside the standards either with comorbidities or with special needs.  Most important to this author is the risk of delaying access to care by long delays of the utilization review process.

 

UR—redeeming qualities

If one is to set aside the concerns voiced above, it is possible that the utilization review process may bolster the legitimacy of the medical profession by clinical guidelines and standards of care.

One area that may be influenced positively is that an external review may hold all practitioners accountable for their decision making and thus weed out the incompetent providers (or at least limit the questionable practices).  This oversight may in turn bolster the public’s confidence in medical care. 

 

It’s all what you make it...

The determination of utilization review as a “bad” process or a “good” is dependent upon the utilization review agencies policies and procedures.  There are many aspects of the process that either encourage or discourage appropriate care and positive outcomes.  There are several areas in which a payer can determine what utilization review process is most appropriate for their population and needs.  

·         How much documentation and paper work must a clinician submit for the UR process?

·         What is the willingness of the utilization review entity to adapt review protocols in response to changes in medicine and/or complaints of the treating providers?

·         To what extent does the UR process take into consideration demographic treatment norms?

·         Are non-physicians allowed to deny authorization for medical treatment?

·         To what extent are physician reviews allowed to deviate from the formal protocols or clinical guidelines of the utilization review vendor?

The reader may want to address the questions above (and others) when choosing a utilization review company.  Much of the angst for utilization review can be overcome by a clinically driven, but patient centered utilization review process.