Latest / Becker’s Payer Issues Podcast / Utilization Management That Works: Strategies, Stories & What’s Next

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Utilization Management That Works: Strategies, Stories & What’s Next · Becker’s Payer Issues Podcast

• 0:00
  Hi, everyone. This is Lucas Voss with Becker's
• 0:02
  Healthcare. Thanks so much for tuning in to
• 0:03
  the Becker's Healthcare podcast series. Very excited to
• 0:07
  talk about today utilization
• 0:09
  management
• 0:10
  that works, story strategies,
• 0:12
  and what's next.
• 0:14
  And I'm also very excited to be joined
• 0:17
  by Chad Kersting, business development director,
• 0:20
  eviCore by Evernorth, and doctor Eric Gracious, national
• 0:23
  physician executive also of eviCore by Evernorth.
• 0:28
  And it's great to have you both on,
• 0:30
  and I wanna start with introductions,
• 0:33
  to get us started here.
• 0:34
  Doctor Gracious, why don't you kick us off?
• 0:37
  Thanks, Lucas, and I appreciate the warm welcome.
• 0:39
  As you said, I'm Eric Gracious. I'm
• 0:42
  currently national physician executive for medical benefit services
• 0:44
  at Epicor by Eber North. I'm a pediatric
• 0:47
  hematologist oncologist by background, as well as a
• 0:50
  general pediatrician, and
• 0:52
  practiced for a number of years before jumping
• 0:53
  into the utilization management business about twelve years
• 0:56
  ago. And I've worn a number of different
• 0:58
  hats over time from patient care to research
• 1:00
  to teaching,
• 1:01
  and, again, most recently in
• 1:04
  utilization management.
• 1:05
  And,
• 1:06
  it's a complex issue, and I'm looking forward
• 1:09
  to digging into it with you today.
• 1:11
  Yeah. Absolutely. Excited to have you on. Chad,
• 1:13
  we'll kick it over to you.
• 1:15
  Thanks. Chad Kersting. I've been with eviCore by
• 1:18
  Evernorth for,
• 1:20
  going on my tenth year now.
• 1:22
  My background is in consumer behavior,
• 1:24
  influencing consumer behavior, changing consumer behavior.
• 1:27
  And, that is the division I started with
• 1:30
  at eviCore and have been able to
• 1:33
  expand,
• 1:34
  that role and and really,
• 1:36
  how can we bring more of that consumerism
• 1:39
  and education
• 1:40
  and things that eviCore was doing on the
• 1:43
  side,
• 1:44
  years ago to be more of a focus
• 1:46
  and and how can we help people? So
• 1:48
  beyond utilization management. So looking forward to having
• 1:51
  a conversation today.
• 1:52
  Yeah. Absolutely. It's exciting to bring both of
• 1:55
  your expertise together for this conversation.
• 1:57
  It's it's very it's great opportunity.
• 2:00
  And I wanna start with doctor Gratias. Utilization
• 2:03
  management, we'll refer to as a as throughout
• 2:06
  the conversation just to make it a little
• 2:07
  bit shorter here, often gets boiled down to
• 2:10
  prior authorization.
• 2:12
  What do you see as the most misunderstood
• 2:14
  or underappreciated
• 2:16
  aspects of today?
• 2:19
  Well, Lucas, thanks for the question. You I
• 2:20
  mean, you you really nailed it with that
• 2:22
  with that lead in. A lot of people
• 2:24
  view
• 2:25
  utilization management and prior authorization
• 2:28
  as the same thing versus interchangeable terms.
• 2:31
  And
• 2:32
  really, prior authorization is one tool that's used
• 2:36
  to manage utilization. So
• 2:39
  utilization management is really
• 2:41
  simply making sure that
• 2:44
  a patient gets all of the health care
• 2:45
  that they need and none of the health
• 2:47
  care that they don't.
• 2:49
  Mhmm. So that includes multiple
• 2:52
  multiple different types of utilization management.
• 2:55
  The most common is addressing what we would
• 2:57
  call over utilization,
• 2:59
  which is when patients are receiving
• 3:01
  health care services that aren't going to benefit
• 3:03
  them in any way at all.
• 3:05
  And
• 3:06
  prior authorization has historically been used to address
• 3:10
  overutilization.
• 3:11
  And overutilization
• 3:12
  management has gotten the the biggest
• 3:15
  component of the attention, which is why the
• 3:18
  terms are interchangeable.
• 3:19
  But what people don't recognize
• 3:21
  is that effective utilization management also addresses misutilization,
• 3:26
  meaning that a person needs health care services,
• 3:29
  but the the health care services that are
• 3:31
  most likely to help them are maybe slightly
• 3:33
  different
• 3:34
  than the ones that are being proposed.
• 3:36
  And so a great example would be someone
• 3:38
  who
• 3:40
  their physician has ordered a CT
• 3:42
  of their head to evaluate,
• 3:45
  something like a headache. But when you look
• 3:47
  at evidence based medicine and apply it to
• 3:48
  that patient for the reasons
• 3:51
  that you're looking
• 3:52
  at their head and their age and their
• 3:55
  other symptoms and things, an MRI would be
• 3:57
  a better study. So utilization management will actually
• 4:00
  connect with that provider and talk through the
• 4:02
  evidence and often result in a change in
• 4:05
  plan to that alternate study, which is gonna
• 4:07
  be better for the patient.
• 4:09
  And then the a bigger component, and,
• 4:11
  you know, it's where Chad and I are
• 4:13
  gonna spend a little bit more focused today
• 4:15
  is on underutilization
• 4:17
  and which is also part of utilization management.
• 4:19
  And this is something that actually quite a
• 4:22
  lot of
• 4:24
  people in health care are engaged in, and
• 4:26
  that's addressing services that people aren't using as
• 4:29
  much as they should. So a really common
• 4:31
  example there
• 4:34
  would be routine vaccination
• 4:36
  or cancer screen
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  or something that we know
• 4:40
  can drive benefits.
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  But people, for a variety of reasons,
• 4:45
  don't use as often as is recommended.
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  And so a lot of hospitals and physician
• 4:51
  groups
• 4:52
  are actually involved in this part of utilization
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  management or the guys of names like gap
• 4:57
  and care closure
• 4:58
  or care coordination.
• 5:00
  And so when you think about utilization management
• 5:02
  more holistically,
• 5:05
  it really encompasses addressing all of those facets
• 5:08
  of inappropriate utilization.
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  And prior authorization is just one of many
• 5:12
  tools we have, which is a workflow processes,
• 5:15
  and it involves
• 5:16
  getting approval for to proceed with the services
• 5:19
  before
• 5:21
  leaping in, to the service delivery.
• 5:24
  Yeah. And you've touched on this a little
• 5:26
  bit, and I wanna come back to it.
• 5:27
  This is sort of a a a follow-up
• 5:28
  to this as well. So what do we
• 5:30
  need to do to shift this? What are
• 5:31
  the shifts that are needed to then improve
• 5:33
  this process to better serve clinicians and patients?
• 5:37
  That's a great that's a great question. So
• 5:39
  there's a number of kind of core principles
• 5:42
  that that you'll hear about out there in
• 5:43
  the world. So one is just broadening understanding.
• 5:46
  And when a kid will understand what utilization
• 5:49
  is supposed to be and that it is
• 5:51
  intended to be a collaborative effort.
• 5:54
  And this should be something where
• 5:57
  all the involved parties are are shooting for
• 5:59
  the same goal, which is the optimal health
• 6:01
  for the patient that's under discussion.
• 6:04
  I think we need more transparency
• 6:06
  around
• 6:07
  what the gaps in care are, what the
• 6:09
  utilization needs are for this person, and what
• 6:11
  are the sources of evidence,
• 6:13
  that are that are used and necessary
• 6:16
  to to help determine that.
• 6:18
  And you can only get there through through
• 6:20
  better information sharing. So there's a lot of
• 6:22
  efforts around
• 6:23
  you hear the word interoperability
• 6:25
  out there, which is essentially just a technical
• 6:28
  term for being able to more easily share
• 6:31
  clinical information or other important information about a
• 6:34
  particular patient
• 6:35
  through electronic means and more in real time.
• 6:38
  So there's not this back and forth of
• 6:40
  phone calls and faxes and
• 6:43
  and other things. And then, you know, the
• 6:44
  the most meaningful thing that we could do
• 6:46
  to really shift that focus
• 6:48
  would be to move the workflow
• 6:51
  further upstream
• 6:52
  so that
• 6:53
  you know, right now, a lot of utilization
• 6:55
  management processes come in after a physician and
• 6:58
  a patient have discussed a course of action
• 7:00
  and come to a decision on how they
• 7:02
  wanna move forward
• 7:04
  with sometimes without the the benefit of some
• 7:06
  of those evidence based
• 7:08
  guidelines being necessary at the point of care
• 7:11
  when that decision is being made. So when
• 7:13
  you start your workflow after that that thoughtful
• 7:16
  process has occurred,
• 7:17
  you've got an entity who's already a little
• 7:19
  bit on the defensive because they feel like
• 7:20
  they're defending a decision they've already come to
• 7:22
  in good faith.
• 7:24
  And if we could be further upstream and
• 7:25
  we were be a technical integration into the
• 7:27
  workflow,
• 7:29
  of that electronic health record,
• 7:31
  you know, and those decision aids around some
• 7:33
  of the evidence were there in EHR at
• 7:35
  the point of care, and we're enabling some
• 7:37
  of those discussions
• 7:39
  between the physician and the patient.
• 7:41
  The combination of that transparency and that technical
• 7:43
  integration of being further upstream.
• 7:45
  If we could somehow, you know, accomplish those
• 7:48
  at scale overnight, the whole discussion around utilization
• 7:50
  management would change.
• 7:52
  You know, we've certainly seen that in pockets
• 7:54
  where we've had, you know, one off opportunities
• 7:56
  to connect at that level,
• 7:58
  with folks that does change the conversation.
• 8:01
  And all of a sudden, this process is
• 8:03
  viewed as a support rather than a barrier.
• 8:06
  Yeah. It's a more active a more proactive
• 8:09
  approach really moving from reactive to proactive, which
• 8:11
  I think is so key.
• 8:13
  You've touched a little bit on underutilization
• 8:16
  as sort of one of the primary pieces,
• 8:18
  and you've mentioned an example there. And I
• 8:19
  wanted to come back to that. So this
• 8:21
  is, of course, talking about members not accessing
• 8:24
  the care they need.
• 8:25
  Can you walk us through an example where
• 8:27
  that was effectively addressed and changed and and
• 8:30
  what organizations
• 8:31
  should really take
• 8:32
  away from it?
• 8:34
  Well, sure. So I'll give you one where
• 8:36
  we we leveraged one of our own workflows.
• 8:38
  And and and again, Chad will go
• 8:40
  into some of this as well. But, you
• 8:42
  know, we have one of our underutilization
• 8:45
  programs involves closing gaps in cancer screening,
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  where we have,
• 8:50
  patients that we know are overdue
• 8:53
  for
• 8:54
  their breast cancer screening like mammography.
• 8:57
  And
• 8:58
  we have, we have the ability to monitor,
• 9:01
  our overall systems. When we when we receive
• 9:04
  a prior authorization request, for example, or again,
• 9:08
  Louxter radiology is an example of radiology study,
• 9:11
  and that comes in as we're about to
• 9:14
  issue an approval for that study,
• 9:16
  the system will run a query and say,
• 9:18
  oh, this patient is on our list of
• 9:19
  people who are overdue for our mammography. And
• 9:22
  that outreach call will be transferred from our
• 9:24
  normal outreach unit to our preventive care team
• 9:26
  who will call that person
• 9:28
  and say, hey. We've just wanna let you
• 9:31
  know that your your MRI has been approved,
• 9:33
  and I hope your hope your shoulder feels
• 9:34
  better and everything goes well with that. But,
• 9:37
  hey. While while I got you on the
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  phone, it looks like you're overdue for your
• 9:40
  mammography.
• 9:41
  You know? And I know you're in your
• 9:42
  shoulder taken care of right now, but certainly
• 9:44
  while we got you here, is there anything
• 9:46
  we can do to kinda help you get
• 9:47
  that closed? And
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  and, you know, and then the person can
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  say, well, you know, gosh. I have. I've
• 9:53
  just been so busy, and
• 9:54
  and we're able to leverage, the network of
• 9:57
  radiology
• 9:58
  facilities in their area. We can go ahead
• 10:00
  and get the study scheduled for them.
• 10:02
  Then we stay with them and follow-up to
• 10:03
  make sure that it was done and they
• 10:05
  got their results. If there was follow-up care,
• 10:06
  we help connect them to that.
• 10:08
  And just by kind of leveraging that existing
• 10:11
  connection,
• 10:12
  we already had where the the person was
• 10:13
  already expecting to hear from us and then
• 10:15
  taking advantage of that moment where we've got
• 10:18
  them engaged on the phone just to try
• 10:20
  to see what else we can do to
• 10:21
  help help them, you know, navigate their care
• 10:24
  and taking the time to actually solve it
• 10:26
  for them in the first call.
• 10:28
  That's an example that we we were helped
• 10:30
  to close a gap in care for that
• 10:32
  for that woman,
• 10:33
  and that wouldn't have existed
• 10:35
  if there wasn't a prior authorization process in
• 10:37
  place for her.
• 10:39
  So the change that really made a difference
• 10:41
  here, you've touched on it before too, was
• 10:43
  the shift to that more proactive approach. Correct?
• 10:47
  Correct. It was the it was the combination
• 10:49
  of being proactive.
• 10:51
  It was just taking the time to stay
• 10:53
  on the call with her and take the
• 10:54
  extra time to, you know, check her, check
• 10:57
  where she lived and see who was available
• 10:58
  and talk to her about her calendar and
• 11:00
  get it all scheduled.
• 11:01
  But, also, I think piggybacking
• 11:03
  on
• 11:05
  a communication channel they were expecting to engage
• 11:08
  with, which is where we have more success
• 11:10
  than a historic approach of a more of
• 11:12
  a cold call.
• 11:14
  Because, you know, we we've all been,
• 11:16
  you know, bombarded by robocalls and spans and
• 11:18
  other things. So peep you know, you know,
• 11:20
  a lot of people just don't pick up
• 11:21
  the phone and answer when they get a
• 11:23
  call from a random number they're not expecting.
• 11:25
  So I think it's the hook of being
• 11:28
  leveraging that communication that we we already have
• 11:30
  in place with them and then taking the
• 11:32
  extra time while we've got them and using
• 11:34
  that moment to help move their care forward.
• 11:37
  Yeah. Absolutely.
• 11:38
  Chad, this is where I wanna bring you
• 11:40
  in and and your expertise
• 11:42
  specifically around the consumer,
• 11:44
  as well. We talked about the proactivity, and
• 11:47
  there is, you know, an increased focus on
• 11:48
  maintaining health through preventative and proactive care. We
• 11:51
  certainly know that as opposed to just treating.
• 11:55
  How is that shift playing out within
• 11:57
  and what's enabling it, and and what are
• 12:00
  you seeing in terms of scalability across US
• 12:02
  Health Care? What does it look like?
• 12:05
  So,
• 12:06
  you know, I think that doctor Graces brings
• 12:08
  up, you know, points out one thing that
• 12:10
  we do really well or and sort of
• 12:12
  changed that that thought process of
• 12:15
  is just being yes or no, but being
• 12:17
  a little more collaborative.
• 12:18
  But but really, it's it's bringing that patient
• 12:21
  into the conversation and
• 12:23
  and understanding what's going on with that person,
• 12:25
  having that conversation with that person to identify
• 12:27
  the barrier.
• 12:29
  And utilization management really allows us to do
• 12:31
  that at a much higher touch point or
• 12:35
  contact level than we would be able to
• 12:37
  do if we didn't have it and what
• 12:39
  most other vendors and health plans have the
• 12:41
  issues with, and that is the contact. You
• 12:43
  know, doctor Gracious
• 12:45
  touched on it, and that is if someone's
• 12:47
  expecting they go to the doctor, the doctor
• 12:49
  says you're gonna need to have an MRI
• 12:51
  or or a CT scan on your knee.
• 12:54
  They've told them they need an authorization. So
• 12:55
  now that person knows,
• 12:58
  that that's the next step. So when their
• 12:59
  health plan shows up on the caller ID
• 13:02
  an hour later,
• 13:03
  they answer the phone. Or when we text,
• 13:05
  let them know we have an update about
• 13:06
  that authorization that drives that inbound phone call.
• 13:08
  So that interaction,
• 13:10
  interaction with the patients and and
• 13:13
  really treating them like a like a person,
• 13:17
  I think is what what's what's a little
• 13:19
  different than what you when you think about
• 13:21
  in the past. And and having that under,
• 13:23
  that it's that
• 13:24
  conversation to understand what's going on with them
• 13:27
  allows us to,
• 13:29
  uncover what that barrier might be, how how
• 13:31
  they've been affected,
• 13:33
  whether it's they can't take time off work
• 13:35
  to get certain things done, to go to
• 13:37
  their wellness visit or get their mammogram,
• 13:39
  or they're waiting two months to see their
• 13:41
  PCP because,
• 13:43
  primary care physicians are in a shortage and
• 13:44
  they didn't know they had virtual benefits. So
• 13:47
  just overcoming that health care illiteracy.
• 13:50
  And where I see this playing out in
• 13:52
  health care is especially as we get more
• 13:54
  virtual offerings,
• 13:56
  as we make it easier to interact with
• 13:59
  patients and customers
• 14:01
  and members
• 14:02
  via either
• 14:04
  some of those apps that are out there
• 14:06
  where we're able to have those two way
• 14:07
  conversations or or two way text conversations that
• 14:10
  that we utilize. But I think you'll see
• 14:12
  it utilized more and more as,
• 14:16
  utilizing that that capability more and more of
• 14:18
  actually interacting with the person to understand what's
• 14:21
  going on in their lives more than just
• 14:23
  case management,
• 14:25
  I think is what's different and where where
• 14:26
  we're headed.
• 14:28
  Yeah. And I think it speaks to the
• 14:29
  fact that, again, we're looking for personalized experiences,
• 14:32
  right, in our day to day lives. We're
• 14:34
  looking for that support that's customized
• 14:36
  to us, more of that consumer experience.
• 14:40
  I'm really curious to see you've touched on
• 14:41
  this a little bit. How do you see
• 14:43
  this trend evolve over the next five year?
• 14:45
  What's going to happen here, especially when you're
• 14:47
  looking at at
• 14:50
  I mean, I think one of the things
• 14:50
  that we've already started to do, and, again,
• 14:53
  doctor Gracious touched on it, earlier, and that
• 14:55
  is, that that person comes in or enters
• 14:58
  a health care journey.
• 15:00
  Knowing what else that person is due for
• 15:02
  or what else is going on in that
• 15:03
  person's life
• 15:05
  as EMRs get more and more connected or
• 15:07
  as
• 15:09
  even, we're able to collect more of the
• 15:11
  results from the scams to know,
• 15:13
  what were the results. And then being able
• 15:15
  to pair that up with either other authorizations
• 15:18
  that we've done
• 15:19
  or if it's Evernorth
• 15:21
  and ESI, what drugs are they on? And
• 15:23
  we get a cardiovascular
• 15:24
  request come in, and we can see they're
• 15:27
  taking this drug, just this drug, this drug,
• 15:29
  and this drug. They've had this pre auth
• 15:31
  pre auth and pre auth. Now they're asking
• 15:33
  for this. Where is this person headed? What
• 15:36
  does this person look like five years ago?
• 15:39
  What do they look like now? And being
• 15:40
  able to predict that and address certain things
• 15:44
  ahead of time, or are they working with
• 15:46
  the right providers? Are they you know, what
• 15:48
  vendors are out there, either the services that
• 15:51
  we offer?
• 15:52
  By looking at the data and seeing what's
• 15:54
  going on with that patient, are they working
• 15:56
  with the the the right groups in the
• 15:59
  to to effectively treat their condition?
• 16:02
  And being able to provide clinical decision support
• 16:05
  to their providers and and looking at things
• 16:07
  holistically.
• 16:08
  Because you sort of pointed out earlier that
• 16:11
  we are in the business historically
• 16:14
  of treating illness.
• 16:16
  People enter the health care system when they're
• 16:18
  already sick.
• 16:19
  But if we have the data on that
• 16:20
  person,
• 16:21
  we can pretty accurately predict what's coming next
• 16:25
  for them. And being able to do that
• 16:27
  at scale
• 16:28
  across our book of business,
• 16:30
  that is something that isn't very far off.
• 16:33
  Yeah. Absolutely.
• 16:35
  Chad and doctor Gracious, I wanna thank you
• 16:37
  both for your insights and time today. This
• 16:39
  is a fantastic conversation. It sounds like proactivity
• 16:42
  is the name of the game, which is
• 16:44
  very, very important.
• 16:45
  We also want to thank our podcast sponsor,
• 16:47
  eviCore by Evanorth, and you could tune in
• 16:50
  to more podcasts from Becker's Health Care by
• 16:52
  visiting our podcast page at beckershospitalreview.com.