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tion at the point of care. When providers and payers wait until after care has been delivered to discuss the care event, opportunities to avoid inappropriate care or use lower cost, high-quality providers are missed; the costs have already been incurred.

Although the pre-authorization process comes before a

claim, it’s an onerous, manual process that requires a great deal of investment by both the providers and payers. Provid- ers prefer automation because they can receive immediate approval on requests. However, it’s not practical to assume automatic approval for every request. With an automated system that is intelligent and exception based, though, each request is resolved much faster, due to the consistent and transparent framework that both provider and plan can share. T at automated system also enables providers to see clinical guidance that is based on widely accepted medical evidence, while also seeing that plan’s specifi c coverage poli- cies – helping the provider make more informed decisions at each point of care. T ere are many more touch points in the care-delivery

process before actual care is delivered and its cost incurred where payers and providers could make shared, evidence- based care decisions. If you can enable transparent decision making at each point of the care continuum, you create real value for both payers and providers and, as a result, the patient.

Rethinking utilization management So what is the fi rst step in which payers and providers can better collaborate to surmount clinical and fi nancial silos to improve care without increasing administrative burden? To move toward a model that will bridge from current to future, we need a new approach to utilization management that

requires shared decision making at each point of care. T e traditional medical-management programs that have been entrenched for decades will not be easy to change, but it is essential that payers and providers embrace a point-of-care approach that leverages smart automation and improved col- laboration to help deliver cost-eff ective care now and build a foundation for long-term success. T is innovative view of utilization management has four guiding principles: 1. Transparent. Payers and providers base their deci- sions on the same, shared information, eliminating contention while improving collaboration and opti- mized decision making.


Actionable. Content is “intelligent” in that it recognizes the context in which it is invoked and automatically delivers specifi c and relevant guidance to the point of care to infl uence decision making. Ide- ally, this guidance combines evidence-based clinical guidelines, plan-specifi c coverage rules and medical and network policies information.

3. Prospective. Relevant information is delivered in real time, before providers deliver care, and is accessible within their workfl ow.

4. Exception based. Automating workfl ows shortens the path from request to decision, giving providers a quick response and low administrative burden in the majority of cases, while allowing health plan clinical staff to focus on the more complex “exceptions” truly requiring their time and expertise. In an ideal world, most of the automation is delivered behind the scenes, with alerts generated only for the exceptions.

T is next-generation approach to utilization manage- ment will rely on innovative technology that suits both payers and providers. Companies, such as McKesson, are working on these point- of-care, decision-support solutions to help our healthcare system make the leap to value-based care. However, it is a process that will require courage, collaboration and compassion from both payers and providers to make it a reality.


1. Casalino LP et al. “What Does it Cost Physician Practices to Interact with Health Plans?” Health Affairs, Volume 28 No. 4 w533-w543. July/August 2009.

2. McKinsey & Company. “Preauthorization sizing.” Proprietary McKesson report, 2008.

The importance of point-of-care decisions. HEALTH MANAGEMENT TECHNOLOGY

3. American Medical Association. “AMA Survey of Physicians on Preauthorization Requirements.” pub/upload/mm/399/preauthorization- survey-highlights.pdf. May 2010.

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