Can Utilization Management Work in a Value-Based World?

Beauty is in the eye of the beholder. And solutions to healthcare’s problems are in the eye of the stakeholder. Payers see the world one way, providers another, and patients still another. Finding solutions that balance stakeholders’ concerns isn’t easy.

But it’s not impossible, if you bring the varying points of view together. I’ve been privileged to work with all stakeholders—payers, providers, and patients—and have heard (and hear) their problems, anxieties, and concerns. It’s from this vantage point that I’ve been wrestling with the problem of utilization management in a world that’s moving rapidly to value-based models.

Today, prior authorization is a blunt instrument that the industry uses in an attempt to solve the nuanced challenge of how to deliver the right care at the right cost. What’s needed is a contemporary way for payers and providers to connect and communicate about cost and evidence at the point of decision—without resorting to phone calls, faxes, or other annoyances and delays to providers and patients.

Complicating this challenge: Both payers and providers are struggling with the complexity of modernizing legacy systems so they can sustain fee-for-service payment models while embracing coming value-based reimbursement models.

In my new white paper, Mastering Change: Succeeding in Healthcare’s New World Order, I propose an innovative model that provides a bridge to value-based decision support. It’s vastly different from the utilization we all know and hate, yet it pragmatically uses the industry’s established UM system as a foundation and a “jumping off” point.

The paper describes a collaborative, exception-based approach that shifts interactions and decisions from post-care to point-of-care. It also prescribes a shared healthcare cloud that gives payers and providers transparency to evidence, quality, and cost, as well as automates authorizations and approvals based on performance and care-event data.

In this model, payers and providers can collaboratively measure, manage, and refine high-quality care delivery while pragmatically reducing administrative costs—and do so with a common shared vision that balances all stakeholders’ concerns.

I hope you’ll download and read the white paper to learn how this practical yet transformative model for exception-based UM and value-based decision making works. And I hope you’ll share your feedback on this new approach to UM with me after you’ve done so.


 To read the full white paper, please DOWNLOAD it here.

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