A national perspective on UR.

A National Perspective on UR

Quality of care is the responsibility of each and every attending physician. There are many definitions of quality, none of which encompasses the universe of medical practice. Care that is neither medically necessary nor appropriate can never be considered good, no matter who renders it or how good the outcome. It is upon these premises that utilization review firms focus.

Utilization review is a part of a larger process of accountability that is just now becoming a part of medical practice. Because of the enormous amount of money involved in the provision of health care services, some method of accountability is appropriate, as a mechanism of both fiscal control and quality monitoring. Utilization review is the most mature part of this accountability process. Its focus initially was on the appropriate site of service. Utilization review firms (local, regional, and national) have focused on review of inpatient vs. outpatient treatment, length of stay, and other inpatient-related programs. There is now significant experience with these elements. The other components of accountability, such as quality assurance, fee review, and out-patient services review, are, as of now, embryonic. To be both cost-effective and clinically sensitive, utilization review must be a "peer process." When there is disagreement from an attending physician over existing criteria, the site of service for an individual patient should be selected only after input is received from knowledgeable, sensitive consultants. Because decisions with respect to site of service must be based on medical necessity, nonphysicians should not participate directly in the review process when an attending physician's choice of site of service differs from accepted guidelines. An appropriate utilization review process results in a recommendation for site of service based on the medical needs of a patient. It should not result in a payment recommendation, a decision that should remain within each benefit plan. The utilization review process should be independent, peer-driven, and consultative in nature. Decisions with respect to site of service should be made on the basis of physician-to-physician discussion whenever discrepancies with established criteria occur. For the utilization review process to proceed smoothly, it must be prospective and concurrent. Retrospective denials are punitive and inappropriate for a profession that operates in real time and must decisively address clinical issues on a day-to-day basis. While patients are not statistics, statistical norms may be applied to individual patients in the practice of medicine. Published articles and scientific advances are all reported in statistical form. Those clinical results that are "statistically significant" become important guideposts as new procedures and drugs are introduced into clinical practice. Statistics, however, represent an aggregate experience. Individual patients require individual attention. This is the essence of the art and science of medicine. When an attending physician phones to begin the review process, his or her call should be answered by a knowledgeable person, such as a registered nurse. If the proposed site of service and length of stay are appropriate and within accepted guidelines, the review process ends. The guidelines used for utilization certification must be based on national experience and must represent valid patterns of medical practice with proven clinical outcomes. Guidelines that represent local practice patterns may not reflect the most cost efficient way of delivering care. Crystallized practice patterns, limited local facilities, or other administrative factors may preclude utilization guidelines that accurately reflect the experience of practitioners in a particular specialty across the nation. When an initial request for certification results in a disagreement between the attending physician and the initial reviewer from the utilization review organization, referral should occur to a board-certified physician. Only another physician can adequately and appropriately discuss the needs of a patient with an attending physician. A clinical discussion can usually result in an appropriate length of stay, with the assurance that patient need will drive the process and that additional hospital days will be certified for medical necessity. The educational process that results from such discussions may often help individual regions of the country become aware of trends that might improve local utilization practices. Sharing national standards and experiences with attending physicians on an individual patient basis is an outstanding educational process. Payers are national, not local. Major medical publications are national, not local. Pathology is national, not local. It is appropirate that physicians interact in a positive, prospective manner, sharing current information. A national review firm brings objectivity to this process. The most appropriate mechanism, therefore, for addressing utilization issues is one that involves a national perspective. A reviewing physician is best not a member of a local community, because a number of biases may enter into any discussion at that level. An independent physician will be more likely to be objective in his or her assessment of medical necessity. Physicians who specialize in utilization review are dedicated to the process and have access to ongoing internal corporate quality assurance activities, continuing medical education programs dedicated to utilization review, and internal audits of their decisions. These points cannot be stressed enough. The motivation of the utilization review physician should be to focus purely on site of services, keeping in mind the needs of the patient. A national utilization review firm needs to have a staff of board-certified physicians spanning many specialties to provide the depth of experience and knowledge necessary to perform its review function. There is no possibility of referral, social, or other relationships damaging the objectivity of the discussion between physicians. A clear and consistent appeal process should be made available to both attending physician and patient each time there is disagreement between physicians. The recommendation of a utilization review firm is then transmitted to the benefit plan. The benefit plan may, however, include factors other than medical necessity in its final payment determination. Utilization review, by definition, should focus its efforts on the most cost efficient site of service and refrain from decisions regarding benefits or payments. Cookbook medicine is not an issue. Proscribed treatment plans are not in the best interests of patients or attending physicians. Algorithms are an inappropriate mechanism of establishing utilization parameters, because they cannot account for patient individuality. Utilization review, focusing on the most appropriate site of service for treatment ordered by an attending physician, should function to heighten the awareness of all attending physicians of the cost of the medical intervention being proposed. Remote off-site review by board-certified physicians with experience in utilization review ensures that any physician-to-physician interaction occurs only at a professional level. There is only one premise that needs to be considered underlying the utilization review process: A patient's treatment plan, as deemed appropriate by the attending physician, should be rendered in the most cost-effective setting. The role of the utilization review process is not to question the judgment of the attending physician, but rather to direct care to the most efficient site. The needs of any individual patient must be defined by his/her attending physician. The guardian of quality of care throughout this country remains the attending physician.

Allan M. Korn, MD, is Vice President, Medical Affairs, HealthCare COMPARE Corporation, Downers Grove, III.