Um Focuses on Telling Doctors and Hospitals What to Do

How can health systems evangelize the right care, at the right price, in the right setting, without overwhelming commitment and reimbursement systems with administrative burden?

The shift from book to value-based care requires the deft combination of value-based delivery (enabled through actionable intelligence and new care commitment models) and value-based payment (enabled through select provider networks and new reimbursement models).

Providers and payers must operate across a transparent, administratively simple, shared ecosystem. This giant spring from today'south world might appear incommunicable; however, as providers take on greater accountability for cost, and share more than chance with payers, there is a real urgency for alter.

The practiced news: the technological capabilities needed to bear on change are available today. What's missing: an effective bridge between the electric current volume-based systems, where communication between providers and payers happens later on the care conclusion (with the express exception of pre-authorization), and a value-based system, where rich data and enhanced intelligence are automatically shared in real-time to inform determination making.

Such a bridge tin be congenital past starting with the current, admitting flawed, pre-authorization model as a foundation, enhancing current cadre systems and investments rather than trying to completely rebuild healthcare. The result is a new form of utilization management (UM) that shifts the remainder of interactions from post-care decision with claims to pre-care decisions.

This tin can be washed through multiple layers of seamless automation that use existing medical information systems (i.due east., electronic health records (EHRs), intendance management portals, etc.) to minimize or even eliminate routine administrative tasks, and empower providers and payers to focus manual medical necessity and authorization review efforts simply on cases that crave their clinical expertise.

This exception-based arroyo increases the value of review and authorization processes by adding bear witness-based decision support to their roles. Past driving advice effectually evidence-based practices and appropriate intendance at the point of decision, the manufacture starts to bring value-based care delivery and, ultimately, value-based payment together.

Solving this applied challenge volition foster genuine collaboration between payers and providers based on a shared priority to ensure that quality care for value is delivered, while significantly reducing their administrative burdens.

The limits of traditional utilization management

The shift to value-based care would seem then logical and promising that nearly all stakeholders would want to support it. The reality is that current payer-provider relationships, their technological systems, and their organizational infrastructures are merely now condign ready to adjust the transition.

In the new world of value, payers and providers should be able to interact effortlessly at the point of care. A patient entered into the system by the provider should automatically trigger the relevant data, processes and tools needed to deliver cost-effective, testify-based quality intendance.

Providers and payers should know the patient'southward relevant intendance history, which approaches and treatments are supported by the testify, and whether those are included in the patient'south insurance benefits package and provider network. The payment of care should be administered nether the advisable reimbursement model, and providers should have shared admission to the information and actionable intelligence needed to evangelize the right care in the right setting.

This is decidedly not the case in the traditional volume-based healthcare system. Pre-authorization and admission review are limited and often flawed examples of opportunities for payers and providers to interact and determine the clinical and fiscal impacts of care.

Under the current approach to UM, providers must seek approval from payers for care through a cumbersome, manual and ofttimes retrospective process.  This puts payers in the position of serving equally guardians of price, medical necessity, network utilization and reimbursement rules.

Traditional utilization management also fails to evangelize rich data on provider utilization patterns and network performance that can be shared between payer and provider. This hinders the development of improved policies, high performing networks and effective, targeted provider interventions.

Non surprisingly, payers and providers view this human relationship as adversarial and the traditional utilization management function as a burdensome but necessary evil, fraught with the potential for conflict.

Co-ordinate to a study from the American Medical Association^one:

• About 64 percent of physicians reported difficulty determining which tests, procedures and drugs require authorizations.
• Almost 63 pct of physicians reported waiting several days for authorization responses on tests and procedures, while 13 percent waited more than a week.
• Nearly all of physicians reported that eliminating potency hassles was "very of import" (78 percent) or "of import" (17 pct).

The per centum of medical claims reporting prior authorization increased on average past two.iii percent from 2011 to 2013, with some payers doubling and tripling the number of care events that require authorization.⁵ Boosted studies institute each preauthorization costs payers and providers between $l and $100, adding to the $74 billion annually² in administrative costs to payers, and increasing the estimated $31 billion in annual administrative costs burdening providers (roughly $68,274 per doc).³

While the complexity and uncertainty created by the shift from book to value-based care is significant, the opportunities created by reform are promising. It is estimated, for example, that enhanced collaboration tin can lead to a significant reduction in the $800 billion lost to administrative inefficiencies, provider inefficiencies and error, medically unnecessary and duplicative care, unwarranted use, and overutilization and fraud and abuse.^four

Shifting to a collaborative exception-based model

Although traditional utilization direction tends to be universally disliked, if transformed into a new collaborative model, information technology could serve as a bridge to the future.

Utilization direction already drives the collection and aggregation of clinical and financial performance data, although it is generally non available for analyses until long afterwards when claims and care management information has been retrieved and reported. That said, it is precisely this assemblage of clinical data that provides an opening for collaboration and for enhancing determination back up in advance of care.

While the administrative burden of conducting a manual review is high, it is possible to automate the authorization process by integrating it into both the payer's and provider's workflows. This would lead to a significant reduction of the transmission work involved in following up on authorization requests likewise equally helping to eliminate redundant medical reviews.

This process could exist further streamlined past programmatically extracting data directly from the electronic health record (EHR) to automatically populate the medical review. Querying the clinical record directly in this way brings obvious advantages to the UM process, reducing the administrative piece of work required for the medical review, and reducing human errors introduced when clinicians manually copy information between multiple systems.

Significantly, from the payer's perspective, automating this process increases the trustworthiness of the review because the clinical data came straight from the EHR—the source of truth—without homo intervention. And when the automated process transfers the clinical values into the medical review, that additional transparency further enhances trust.

In this scenario, immediate approval could be generated based on medical review results coupled with the payer'south business rules. Automated decisions could also take into account data on provider utilization patterns and network functioning.

The power to configure options based on the utilization patterns of a provider or care upshot is important to developing a collaborative win-win relationship between a payer and its providers. The more the provider's practices are in line with prove and policy, the lower the authoritative burden.

Both the payer and provider tin can see this practice data—the provider can demonstrate proficiency, and the payer can monitor and incentivize provider participation without the burden of a transmission discussion. In the process, the provider will know automatically if care events are covered, what the appropriate medical and network polices are, and whether they require a deep manual review or but a notification as they are making their decisions and before the intendance is delivered.

To drive optimal provider adoption, this must be done across care events—diagnostics, procedures, specialty drugs, DME, etc.—and beyond their various payers, bringing a familiar, mutual workflow to the user, which is much more attractive than having to go to multiple systems for multiple payers.

Optimizing utilization processes with analytics

How does a payer go along to manage authorizations that are approved the majority of the time, without intervening in the care commitment procedure excessively? The information generated by automation must be gathered in a cloud-based shared ecosystem, measured and smartly managed by exception.

In this style, the payer intervenes only to the caste necessary. If the provider is delivering appropriate, evidence-based care, then the burden of scrutiny should be minimized and information technology should exist easier for the provider to deliver and be reimbursed for care. That is the formula for a collaborative payer-provider relationship and one needed for value-based care.

To empathise when interventions tin be minimized, payers must measure and manage utilization patterns, while refining policies and processes.

1. Measure Measuring utilization data requires examining it in aggregate as part of an overall trend, rather than in terms of individual authorizations. Doing and so makes apparent which requests are being automatically canonical and which are automatically reviewed or canceled, and how frequently such interventions happen. This can be done based on the program, product, provider, patient or care event.
2. Manage Drilling down, payers can compare utilization patterns of different networks and providers, and observe variations in intendance events and procedures. Accordingly, the health plan tin place outliers where requests are higher volume compared to the peer-gear up norm, in or out of network, or not in line with testify-based approaches. In addition, it can also see when requests are routine and do not warrant additional scrutiny that would waste administrative resources. Based on this data analysis, the health plan can build a nuanced exception-based arroyo by refining and optimizing its rules of authorization to facilitate the blessing of requests that are aligned with quality and cost objectives while triggering notification in the arrangement to scrutinize requests that are outside of their set parameters.
3. Refine Once a system is in place to automate routine requests and signal alerts well-nigh outliers, the wellness program and the provider can work together to understand the root causes of the outliers and intervene equally appropriate. Ultimately, this collaboration tin result in improved performance for the organization from both authoritative and medical toll perspectives that benefit the provider and the payer alike. This tin likewise serve as key performance data for value-based relationships between them.

The more providers can align their care practices with the benefits and policies of the payer, the more providers will avoid the authoritative brunt of utilization direction and be amend able to demonstrate their value to a payer's narrow network.

Performance-driven collaboration

In a value-based system, we are striving toward collaboration. How tin exception-based utilization management be implemented, and what are the benefits of this model for both parties?

In this system, payers and providers communicate about intendance commitment in near existent-time and acquire to develop a more than nuanced agreement of utilization patterns and variations in intendance. Over time, payer rules and actionable content tin can exist infused into the many points of decision that are being made past the provider. This will help decide the appropriateness of medical intendance while too reducing administrative burdens. Near significantly, it creates a traversable pathway to a value-based care system.

This approach engages providers and payers with a mutual language. They are using a shared technology to mensurate, manage and refine quality care delivery in line with coverage policy. It reduces barriers internally, and between payers and providers, so that the various functions can communicate across traditional silos. Eventually, this also opens the door to integrate shared rules into the provider'south workflow.

This is an essential bridge from volume to value. When utilization patterns and the benefits of improved performance are shared openly, the provider can organize its care commitment to bulldoze value, and the wellness plan can incent or support such efforts by paying for value. Over time, payers volition straight more than care to the all-time performing providers, equally defined by their power to meet quality and cost goals in accord with evidence. The all-time providers volition work to increasingly align their practices to run into the payer's definition of value.

Making the vision real

A transformative arrangement is well within achieve. It starts with the engineering science tools and platforms being developed today, and the collaborative ecosystem forming among the network of payers, providers and vendors across the healthcare infinite.

By fully automating the authorization procedure, redundancy—where both payers and providers perform the aforementioned medical reviews—tin can exist eliminated, and authorizations can be provided without needing to manually handle the request. This helps reduce administrative costs, speed authorizations, and helps ensure advisable care.

Exception-based UM is at present a reality, and the elimination of the adversarial relationship heralds ameliorate days ahead for payers, providers and patients.

About the Author:

Nilo Mehrabian: Vice President, Product Direction, Decision Back up, Modify Healthcare

Nilo Mehrabian has more than 25 years of experience in the healthcare market, serving the last 20 years in healthcare IT. She is responsible for the Determination Support products at Change Healthcare.

Footnotes

¹American Medical Association, AMA Survey of Physicians on Preauthorization Requirements (May 2010)

^twoMedical Economic science, Curing the prior authorization headache (October, 2013)

³McKinsey & Visitor, Preauthorization sizing, McKesson report (2008)

⁴Health Affairs, What Does it Price Medico Practices to Collaborate with Health Plans? (July/August 2009)

^vThomson Reuters written report, http://www.reuters.com/article/usa-healthcare-waste-idUSN2516799520091026 (October, 2009)

^sixAmerican Hospital Association, Study: 75% of hospitals have at least a basic EHR (Nov, 2015)

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Source: https://www.healthcareitnews.com/news/reinventing-utilization-management-um-bring-value-point-care

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