Health systems and health insurance plans spend enormous sums of money battling over how to be paid fairly — and these battles have only intensified with the growth of Medicare Advantage plans, which deny care at increasingly high rates. Who’s right? In truth, both sides have valid points.
Physicians sometimes overuse services or perform surgeries that don’t meet robust appropriateness criteria. Meanwhile, health plans often deny care that is appropriate, necessary and beneficial for patients.
At our institution, we sought to break this impasse by creating an innovative new process, centered around a newly established role: the chief medical officer for utilization management and resource utilization (CMOUM). Reporting to the chief clinical transformation and quality officer, this leader built and trained a dedicated team of physician advisors — hospitalists and emergency medicine physicians employed by our health system, not contracted from outside vendors.
By directly employing these physician advisors, we can staff the utilization review program 12 hours per day, every day of the year, enabling review of up to 100 cases daily and conducting 20 to 25 peer-to-peer calls with payers. Initially costing less than $1 million annually, the program has returned 10 to 20 times that investment each year since it began in 2020. Today, it covers 14 hospitals across our system and continues to expand.
Beyond utilization reviews, physician advisors have been trained in clinical documentation integrity, helping improve our case mix index. They also participate in daily observation huddles to ensure patients are accurately classified to reduce inappropriate observation status.
This success is made possible by a highly collaborative effort among utilization management nurses, hospitalists, transition care managers, operations engineers and physician advisors.
Building on this momentum, the CMOUM and physician advisors are now leading new initiatives aimed at lowering cost per discharge. Efforts include reducing blood product and operating room supply waste, and promoting appropriate ordering of MRIs, echocardiograms, pharmaceuticals and laboratory tests.
Underlying all these improvements is a deeper cultural transformation we call “living and leading with love.” This model invites all caregivers to believe their job is not only to deliver care but to continuously improve its value. It fosters a learning community where respect, open communication and shared ideas drive progress. A critical piece of this model is shared accountability: Leaders are responsible for equipping caregivers with the tools they need to succeed, and performance is transparently stratified by hospital and clinician to both celebrate successes and offer targeted support.
As our CMOUM and physician advisors bring this culture to life, we see even greater potential ahead. When utilization management, clinical documentation, resource stewardship and revenue cycle are treated as essential elements of quality, the ultimate beneficiaries are our patients.
Peter J. Pronovost, MD, PhD is Chief Quality & Clinical Transformation Officer and the Veale Distinguished Chair in Leadership and Clinical Transformation at University Hospitals in Cleveland.
Anthony John Muni, MD, is Chief Medical Officer, System Utilization Management at University Hospitals in Cleveland.
