Value-based care requires collaboration between payers and providers to ensure the patient receives the most appropriate care in the most appropriate setting. However, the current utilization management process — preauthorization — is time-consuming, costly and frustrating for all involved, says Matthew Zubiller, vice president at McKesson Health Solutions.
"Traditional utilization management... is where a provider has to ask [a payer] beforehand to get authorization to proceed with a surgery or a special drug," he says. "It's a very manual process, it requires a lot of documentation — it's almost as if it's the last century when we were all still using phone calls and faxes to communicate."
It's also costly for payers and providers alike. The amount of administrative work required by manual preauthorization means each case costs both the payer and provider between $50 and $100. And while the provider is getting preauthorization, the patient is waiting for the procedure or treatment. The process is still used, however, as it's currently the most effective way to achieve utilization management.
"Right now, it's a necessary evil," he says. "It maintains proper utilization of care but it costs a lot and isn't liked."
Mr. Zubiller believes the answer to better utilization management lies in technology. He suggests a solution akin to clinical decision support software, which would either ask the clinician a series of questions or pull data directly from the patient's EHR and run that information through a payer-designed algorithm. If certain qualifications were met, the procedure could be approved automatically and instantly. Complex cases needing manual review could still be sent to the provider. The system could also send notifications to the provider about other, cheaper care options or settings.
Using a solution like this would also create a large trove of data, giving payers information on which providers are submitting approvals for which services, and the overall approval rates. Combined with outcomes or claims data, this information could be used to tweak the payers' algorithms to improve utilization management.
It wouldn't be a complete overhaul of the current, preauthorization-based utilization management system, says Mr. Zubiller, but a bridge to a new, value-driven healthcare industry characterized by greater provider-payer collaboration.
"There's been a lot of talk about moving to a value-based model and tangible and practical way to make those first steps," he says. "If we can transform our utilization management [this way] and alert physicians in a meaningful way about better options or better care plans ... then we're not just firing off information that's not intelligent or actionable — when it's not just preauthorizations but also care alerts — then we're evolving the current system and finding new opportunities for collaboration."
For more on Mr. Zubiller's viewpoint, please read his whitepaper.
More articles on utilization management:
Valence, Centegra Partner to Support Clinically Integrated Network
4 Key Steps for Provider-Sponsored Health Plans
Can Clinical Decision Support Reduce Inappropriate Utilization of Imaging?