Don't waste your Utilization Management Resources

To survive in today's managed care environment, health care organizations must be a cost-efficient, high quality provider of health care services, and prove to others that they are a cost-efficient, high quality provider of health care services. The predominant factors that affect an organization's ability to be a cost-efficient, high quality provider of health care services are listed below:

The delivery system is not conducive to cost efficient patient care

For example:

Outdated or inefficiently designed physical plant

Inflexible delivery system (insufficient number of out-of-hospital patient care services, no subacute care alternatives, etc.)

Health care is not coordinated in and among provider sites

No gatekeepers

Patients/families lack an understanding of the managed care environment

Tests/treatments do not need to be performed or are performed while the patient is in a high-cost environment

For example:

Inadequate provider/caregiver education about reimbursement incentives
No pre-authorization or appropriateness-screening system exists for high-cost tests/treatments
Tests/treatments are performed for patient/caregiver convenience

Wide variations exist in patient care practices

For example:

Providers have differing practice patterns with no discernable differences in patient outcomes
Diversity in practices among nurses and other caregivers inhibits communication and coordination among the health care team

The responsibility for effective resource management is too far removed from the direct caregiver

For example:

Providers assume no personal responsibility for cost efficient care
Bedside caregivers are not delegated any responsibility for case management, utilization review, or discharge planning — leaving these activities up to personnel who are not on the job 24 hours a day, 7 days a week like direct patient caregivers
Clinical support staff (e.g. respiratory therapists, dieticians, rehabilitation technicians, etc.) are not knowledgeable about their role in effective resource management

Many different types of initiatives will be necessary to overcome these factors. In selecting resource management projects, consider the following suggestions:

Choose those projects that will impact processes that are highly important to achieving your organization's managed care objectives. Identify important patient care processes which are not performed very well right now (based on data). Don't waste time being better than required at unimportant tasks.
Determine the potential impact of the interventions on controlling costs and maximizing quality. The resources allocated to the intervention should be commensurate with the improvements ( quality, Ż costs, satisfaction, etc. ) expected from successful implementation. Build cost-benefit analyses into your implementation strategy.
Focus your interventions on those case types with the greatest potential for improvements. Concentrate your patient-directed tactics on categories of patients mostly likely to benefit.

Don't waste your resource management resources on projects that don't give you a return on your investment. Over time you'll find that all the factors affecting your ability to be a cost-efficient provider can be addressed — but if you try to deal with everything at one time, you'll find yourself overwhelmed with unfinished projects.

Š 1997 Brown-Spath & Associates.

To Learn More: Patrice L. Spath is available for inhouse presentations on this and other health care quality improvement topics. For further details, visit the Brown-Spath & Associates' web page at http://www.brownspath.com. Address comments or correspondence to: Brown-Spath & Associates, PO Box 721, Forest Grove, OR 97116.

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