Utilization management (UM) in U.S. healthcare

 Utilization management (UM) in U.S. healthcare involves the management of healthcare resources and services to ensure that they are used efficiently and effectively. 

Key components:  Preauthorization, concurrent review, retrospective review, clinical guidelines adherence, case management efficiency, and cost containment efforts. 

UM programs aim to strike a balance between providing high-quality care and controlling costs. 

These programs are commonly used by insurance companies, managed care organizations, and healthcare providers to assess the medical necessity, appropriateness, and efficiency of healthcare services and interventions.

1. Preauthorization Rate: This metric assesses the percentage of requested healthcare services that require preauthorization before being approved. A higher preauthorization rate may indicate a more comprehensive UM program.

   - Example: A patient's request for elective surgery is subject to preauthorization. The UM team reviews the medical records and decides whether the procedure is medically necessary.

2. Concurrent Review Length: This metric measures the average duration of concurrent review for patients receiving ongoing care. Longer concurrent review times can lead to delays in treatment.

   - Example: A patient with a complex medical condition is undergoing a series of chemotherapy sessions. The UM team regularly assesses the treatment to ensure its effectiveness and necessity.

3. Retrospective Review Outcomes: This metric evaluates the percentage of retrospective reviews that result in the denial or approval of previously provided services. A high denial rate may indicate issues with initial service appropriateness.

   - Example: After a patient has received outpatient physical therapy for several months, the insurance company conducts a retrospective review to determine if the treatment was medically necessary.

4. Clinical Guideline Adherence: This metric assesses the extent to which healthcare providers and facilities adhere to established clinical guidelines for specific medical conditions or treatments.

   - Example: A UM program monitors whether healthcare providers are following recommended guidelines for managing patients with diabetes and reviews the outcomes.

5. Case Management Efficiency: This metric measures the timeliness and effectiveness of case management interventions for individuals with complex or chronic health conditions.

   - Example: A patient with multiple chronic conditions is assigned a case manager who develops and monitors a care plan to ensure the patient receives appropriate care and avoids unnecessary hospitalizations.

6. Cost Savings: UM programs are often evaluated based on their ability to control costs while maintaining quality. This metric calculates the cost savings achieved through UM efforts.

   - Example: By implementing UM procedures, an insurance company may reduce the costs associated with unnecessary hospital admissions, leading to cost savings.

7. Patient Satisfaction: While not a traditional metric, patient satisfaction surveys can provide valuable feedback on the impact of UM on the patient experience.

   - Example: After navigating the preauthorization process for a necessary medical procedure, a patient may provide feedback on their experience, which can be used to improve the UM process.

8. Denial Rate: The percentage of requested services that are denied based on UM criteria. A high denial rate can indicate potential access issues for patients.

   - Example: A patient's request for a certain prescription medication is denied due to the availability of lower-cost alternatives that are equally effective.

UM metrics help healthcare organizations and insurance companies assess the effectiveness and efficiency of their utilization management programs, ensuring that patients receive appropriate care while controlling costs and improving overall quality of care.

Related personnel:

a. Utilization review nurse :  

# Check patient medical records, looking for any aberration or oversight in care

# Review and analyze the treatments patients have received in an effort to ensure they are both effective and cost-efficient

# Interface with patients, doctors and other nurses regarding the status of patient care and, when needed, suggest changes to patient care methods or facilities

# Educate patients on the benefits and restrictions of their private healthcare providers, as well as Medicare and Medicaid

# Assist in discharge planning, helping patients transition from in-patient to at-home care.

b. Case manager