Utilization Management – Helping the Patient
Information and informational access is critical in optimizing utilization in healthcare
By Jay I. Pomerantz, MD – Executive Medical Director for Health Integrated
As I have shared with you the last couple of weeks, utilization management (UM) is a key to achieving the top goals in healthcare reform – improving patient outcomes while reducing overall cost. The interactions between the physician and the patient are a critical part of the process, particularly in a time where information is free flowing and readily accessible. Both physicians and patients have access to more data than ever before, and it has the potential to help steer and navigate decisions.
Utilization management is a balance – a data-driven balance. The cost/outcome equilibrium of making decisions about the health of a patient is driven by evidence-based information which supports a recommended therapy, and then dosed with the related cost of the treatment. UM by design is intended to ensure quality, appropriateness and efficiency of care and resources. This balance can be seen in some clinical management practices which limit or substitute care and treatment based solely on cost efficiencies. These decisions will likely have a negative long-term effect on outcomes and then subsequently on the very costs they are employed to save. In today’s environment though, these examples are clearly in the minority. All of the stakeholders in the healthcare system – the provider, the physician, the more-informed patient, the employer and other support organizations – realize that any cost-only strategy offers only short-term gain. The long-term costs, both in health and related expense, are negatively affected. Much of this has to do with today’s patient. They are increasingly informed – seeking information and thus more involved in their own healthcare and more participatory.
It is more the case now than ever before, when a typical patient meets with a physician today, they come fully armed with the latest studies and information related to their ailment. The physician has the role not only to determine relevancy of the patient-provided data, but to augment with information of their own. From the patient’s perspective, this is not only a check and balance, but it allows more involvement in the decision-making process about their healthcare. All of this goes back to the premise that I have yet to see disproved; the more and better information we possess, the better decisions we make. That goes for the physician and the patient. Better input, better outcomes.
Sounds logical.
One of the key pillars in the recent healthcare debate swirled around evidence-based medicine. We heard the debates concerning the breast cancer argument, and more recently the prostate cancer diagnostic protocol discussion – to test or not to test was the question. Regardless if you agree or not with these debates, decisions for these and countless other medical scenarios are best made if steeped in solid clinical and outcome-based evidence. This information allows the clinician to better lead a treatment protocol to optimize utilization for that particular patient scenario.
Patient-based decisions are no different. As clinicians, we can help the patient collect, analyze and understand the implications of the information gathered so they become active in their healthcare – engaged throughout the process – so to gain their buy in and support for the decision path we have collectively selected. This allows us to participate, to collaborate in a decision that can have little or great significance in the life of a patient. As well, this process helps to improve the choices made thus optimizing utilization and achieving the overall benefit – better outcomes and lower costs.
The bottom line – in order to manage and optimize utilization, information is the key. Information opens the door to better decision making and although the physician will always be the quarterback, having access to information allows all stakeholders a place at the table where better and more informed decisions can be made to everyone’s benefit.
What do you think?
Thanks for reading. I would also welcome your thoughts on topics that would interest you. Please contact me directly at healthexecforum@healthintegrated.com, or you can comment directly in the blog.
Best Regards,
Jay I. Pomerantz, MD
