Utilization management (UM) programs were put in place to facilitate clinically appropriate patient treatment plans and cost effective care. UM is used prior to pre-authorization during concurrent review and after a patient is discharged from a hospital or other clinical setting. As a result of the information gathered in UM, connections to disease management, care management, and population health program offerings can be linked to UM programs with collaboration between providers, payers and patients.
How Health Plan Leaders Review UM
As reported by Medecision, less than 32% of health plan leaders rate their UM tools as “very effective” at identifying health events in time to have a positive impact. An estimated 25% of health plan leaders said the UM tools are “easy to use”. This data reflects that some regard UM programs as fragmented and challenging. In the February 25, 2024, webinar titled “The State of Utilization Management 2024,” the top barriers to UM were discussed along with how healthcare leaders can address them. The expert speakers on the webinar were Julie Barnes, founder and CEO of Maverick Health Policy, Kenneth Young, President and CEO of Medecision, Stephanie Kovalick, Partner and CSO of Sage Growth Partners
In the webinar, independent market researchers surveyed health plan leaders about the current state of UM. This research was examined along with what organizations need to do to transform UM and Care Management programs.
The Findings
Among the important findings of the webinar and aforementioned UM data were the following:
- Over 50% of those surveyed point to fragmented data (57%), data that doesn’t flow into UM workflows (55%) and burdensome data integration are the top barriers to current UM tools.
- 68% say inefficient workflows are an organization’s primary frustration with current UM tools, followed by high costs associated with data silos (49%) and provider abrasion (40%).
- Respondents say the current tools are not easy to use and they require technologies that are “very effective” at accessing real-time data to drive down costs.
- The power of personalization in making UM more valuable by plan members and providers.
- How predictive modeling for risk stratification, as well as UM workflow optimization with AI and automation can propel UM efficiency, results and outcomes.
- What leaders should understand about regulations relative to UM including the newly-released prior authorization rule.