Penrod Blog

Utilization Management as a Value-Based Care Strategy

Written by Matt Fiel

At its core, utilization management analyzes trends in healthcare service use. It determines if these services comply with best practices and clinical guidelines. Traditionally, Utilization management (UM) was viewed primarily as a cost-control measure rather than a tool for enhancing service quality.

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The value-based care strategy requires connecting a patient’s health ecosystem, which includes primary care, specialty clinics, and payers. Discrepancies in this ecosystem have a significant influence on patient treatment and results. This shift in approach highlights the need to implement utilization management so patients receive adequate care at the right time. It is consistent with the overarching objective of providing high-quality healthcare, reflecting the industry’s transition to a more holistic and patient-centered approach.

Understanding Value-Based Care

Value-based care is a healthcare framework that focuses on providing high-quality treatment to patients while improving their results. Unlike traditional Fee-For-Service models, which reward more treatments regardless of the outcome, value-based care prioritizes quality. In this model, healthcare providers are compensated based on the quality of treatment rather than the volume of services they offer. This approach enables physicians to focus on patient outcomes, efficiently coordinate treatment, and manage population health, resulting in better results and reduced costs.

A significant benefit of value-based care is that it encourages collaboration and shared risk among healthcare providers. Teamwork can enhance care coordination, improve patient outcomes, and lower healthcare costs. Value-based care evaluates healthcare providers’ performance using quality indicators such as patient health outcomes, care coordination, and patient satisfaction. It also emphasizes the significance of care and population health management, holding doctors accountable for their patient group’s total health rather than individual patients.

Why is Utilization Management Important in Healthcare?

Utilization management looks into the effectiveness and need for various medical treatments, procedures, and facilities for patients. Utilization management avoids unneeded treatments by providing an organized treatment plan, resulting in lower costs while maintaining high-quality care. Adherence to set procedures improves system efficiency, reduces waste, and gives caregivers more time with patients. Utilization management assesses various procedures, including patient admissions, home health visits, emergency room visits, outpatient visits, primary care physician visits, specialist referrals, high-cost imaging, and visit costs.

Although insurance companies often monitor this process, healthcare providers can adopt techniques to maximize their resources and care delivery, thereby reducing costs while improving patient outcomes. Clear guidelines in utilization management reduce administrative responsibilities for medical professionals, allowing them to focus on patient care. This improves job satisfaction and lowers the danger of burnout, an ongoing issue among today’s practitioners.

The benefits extend to promoting mutual understanding between providers and payors, ensuring smooth coordination, and reducing errors due to miscommunication. This is consistent with regulatory norms and underscores the need for usage management in today’s healthcare settings and modern research procedures.

Utilization management involves three different assessment processes, and the completion steps vary depending on the chosen method.

Types of Utilization Management

Utilization management involves a carefully coordinated process covering authorization, review, communication, and analysis. The key objectives are to guarantee effective utilization of healthcare resources and services, manage costs, and improve overall quality. Each form of utilization management review serves a specific purpose. Key components include:

  • Prior Authorization or Prospective Review: Conducted before treatment begins, it identifies necessary services for the patient while eliminating redundant or inappropriate treatments. This process aims to enhance ROI by avoiding unnecessary expenses over time.
  • Concurrent Review: An ongoing review of a patient’s treatment plan during service delivery. This includes care coordination, which ensures coherence when many clinicians or experts are involved. It also includes discharge planning, establishing milestones for a patient’s departure from the hospital, and transitioning care between levels of care.
  • Retrospective Review: This takes place after a procedure’s completion to evaluate its effectiveness and suitability. Findings guide decisions on whether similar treatments can be provided to other patients with similar conditions. This assessment is crucial for insurance claims, ensuring appropriate compensation, and challenging claim denials.

In cases where proven treatments are not utilized and a claim is denied, the caregiver bears the financial burden. The process determines whether reimbursements are correct or a claim should be denied. The review can be done again if there’s an appeal or a complaint.

A retrospective review is not limited to the end of a procedure; it can also occur at a crucial moment during treatment. The patient’s treatment might revert to an earlier stage in such cases. This happens when the patient does not respond well, there is a change in diagnosis, or other restrictions apply, such as a change in the patient’s insurance coverage.

Utilization Management for Salesforce Health Cloud

Transitioning from fee-for-service to value-based care requires a significant overhaul in healthcare administration and reimbursement techniques. A digital solution for utilization management is crucial in streamlining workflows, optimizing care coordination, and automating communication with payers. Salesforce Health Cloud is a good fit for developing utilization management use cases because of its flexibility, declarative processes, and HIPAA compliance.

Salesforce Health Cloud makes personalized care easier by customizing the patient journey, optimizing operations, and delivering user-friendly dashboards with secure, comprehensive reporting choices. And this is only the beginning.

Salesforce Health Cloud Key Features:

Healthcare providers committed to providing value-based care utilize Health Cloud and other Salesforce solutions to streamline operations, improve health outcomes, and customize patient experiences. As the need for value-based care, transparency, and patient-centered healthcare develops, providers will need to embrace innovative technologies such as Health Cloud to satisfy rapidly evolving patient expectations.

Salesforce Health Cloud enables healthcare personnel to easily manage inquiries, from appointment booking to linking patients with the appropriate physician, all from a single interface. It improves the patient experience by providing a unique 360-degree perspective of the patient, integrating with electronic health records (EHR), and implementing revolutionary AI technologies and processes.

Health Cloud provides essential functionality for payers, allowing insurance providers to access a patient’s available coverage at both in-network and out-of-network costs. Integrating health insurance and healthcare improves efficiency for patients, providers, and payers, making it an outstanding benefit.

Penrod’s Final Take

In simple terms, Utilization Management significantly benefits payers, providers, and members. Payers profit from cost-effective healthcare by reviewing and approving appropriate treatments while reducing needless costs.

Providers get streamlined workflows, improved care coordination, and better communication with payers, improving resource use and efficiency.

Members also benefit from receiving the proper care at the right time, which promotes healthier outcomes and reduces delays.

Salesforce Health Cloud streamlines utilization management processes, promoting seamless communication between healthcare providers and payers to ensure optimal care coordination. This ensures that patients get the proper care at the right time. With easy submission of care requests for pre-authorization, Salesforce Health Cloud addresses the challenges associated with utilization management and care coordination, making it possible for healthcare providers to deliver personalized and streamlined care for optimal patient outcomes.

About The Author

Matt Fiel

EVP of Marketing

With over 15 years of experience in marketing strategy, web development, and creative design, I lead the marketing team at Penrod, a boutique Salesforce partner focused on the healthcare and life sciences industry. As a Salesforce Certified Pardot Consultant, I have deep knowledge and skills in leveraging the platform to optimize marketing automation, lead generation, and customer engagement.

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