The Role of Utilization Management in Case Management
By Pat Stricker, RN, M Ed
VP of Clinical and Client Services
TCS Healthcare Technologies
A priority of every case management intervention is to support the patient to make sure that they are getting the best care and support over a continuum of time to achieve positive clinical outcomes. However, case managers also need to deal with the “medical appropriateness” or “medical necessity” of care. This function is referred to as “utilization review” or “utilization management” (referred to collectively as “UM”).
Clearly, UM oversight does have a role in case management interventions. We are reminded of this relationship by a 2002 CMSA/URAC regulatory study that showed over a dozen states reference UM programs when defining the practice of case management.1 In addition, the CMSA’s Standards of Practice for Case Management highlights the close relationship between UM and case management programs when defining “managed care.”2
UM interventions help ensure that patients receive the “right care at the right time” to improve clinical outcomes and lower costs. UM’s goal is not meant to merely “limit or restrict” care, but to assure that “appropriate” care is received. The Institute of Medicine (IOM), the Robert Wood Johnson (RWJ) foundation and other experts have highlighted the overuse and underuse of healthcare services, and that either of these can result in the potential risks that can greatly outweigh any potential benefits. For example, spending and doing more does not necessarily equate to better care.3 A recent Health Affairs article also highlights that private insurers do a better job controlling costs than Medicare by using UM programs. 4
Evidence-based, decision support criteria from Milliman, InterQual and others are an essential part of any UM program by providing objective criteria to help determine the “right” care. Managed guidelines for conditions, particularly where there is wide practice variation, present a means of increasing cost effectiveness while improving outcomes across the board.
Over or under-utilization can lead to lower quality care with higher costs and health risks. But UM, in combination with evidence-based treatment guidelines and standardized clinical pathways, helps to determine what is medically necessary, and as a result, enhances the quality and effectiveness of a patient’s care. It represents an evidence-based approach to optimize care, while eliminating excessive treatment and expense.
To further that end, case management software applications must provide case managers with easy access to information, enhanced documentation, and improved accountability. The application needs to be integrated with other sources of patient information, (i.e., claims, lab results, medications, health risk assessments, UM and DM data, etc.), so all the data needed for decision-making is available in one integrated system. Based on this information and built-in business rules, the application should be able to automatically present appropriate care options to the case manager, so he/she can develop individualized care plans that meet the unique needs of each patient.
The good news is that technology now offers these types of functionality that were only dreamed about a few years ago. They provide case managers and other caregivers with the ability to develop automated high-level care plans that provide each patient with the “right care at the right time”.
To contact Pat Stricker:
Email her at firstname.lastname@example.org or
reach her by phone at (530) 886-1700 ext. 215.
- “Government Oversight of Case Management: 2002 Survey,” Case Management Trends: An Overview of Recent Industry and Regulatory Developments (CMSA/URAC 2002).
- “The Standards of Practice for Case Management” (CMSA 2010) http://www.cmsa.org/SOP.
- See http://www.rwjf.org/files/research/currentstateofquality.pdf
- See http://www.healthaffairs.org/press/2010_12_07.php. See “McAllen and El Paso Revisited: Medicare Variations Not Always Reflected In The Under-Sixty-Five Population” Health Affairs (December 2010, Vol. 29, no. 12, pgs. 2302-2309)