● Decision Support
Rethinking traditional utilization
and are working to determine the next steps to move to this new model. T e reality is that our current healthcare infra- structure is not yet ready for a value-based model. What if, amidst the uncertainty, we could identify strategic constants in the healthcare system today upon which we could build our future – a foundation and bridge from the healthcare world of today to tomorrow? One of those constants may be utilization management
(UM) – yet not the traditional UM we all know today. We would need to move traditional UM toward an exception- based, shared decision-support model that provides intelligent and actionable content to both payers and providers. It needs to help them determine the appropriateness of the care at each point where there is a care decision to be made. While traditional UM is often a source of contention and signifi cant administrative cost, it is perhaps the one dimension of the current paradigm where payers and providers can eff ectively communicate, prior to care delivery and incurring costs.
s healthcare reform continues to evolve, the shift toward a value-based system is underway and inevitable. However, many healthcare stakehold- ers are still grappling with massive uncertainty
management T e shiſt to prospective, exception-based decision support at the point of care. By Matthew Zubiller
Matthew Zubiller is vice president, decision management, McKesson Health Solutions.
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The problem with traditional payer programs Traditional payer programs require expensive, manual
resources and do not adequately engage providers. Costs to providers to administer payer processes, such as utilization management, have been estimated at $31 billion annually.1 T e time and eff ort required to process authorization re- quests – combined with a response time of several days or more – slows the care-delivery process, adds ineffi ciencies and frustrates relationships with providers and their payers.
Payers and providers have the same problem. They need to work collaboratively to solve it.
At the same time, these processes are also ineffi cient
for payers. For example, 90 percent of pre-authorizations require phone or fax communications, which take time and add up to $50 to $100 in payer costs on average per authorization.2 In addition, they fail to deliver the desired results. Experts estimate 17 to 20 percent of medical care is unwarranted, including unnecessary hospitalizations and duplicative tests.3
Using shared, actionable and intelligent decision support starts payer-provider collaboration today.
16 September 2013
Point-of-care decisions are critical to realize real value A key contributor to these costs is the inconsistency in clinical decision making that often occurs when payers and providers rely on traditional, manual utilization-management processes and incomplete coverage and network informa-
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