Utilization review: Another job for hospital case/business managers?
UR professionals who lack clinical credentials lose jobs
The trend is clear, experts say: At hospitals around the country, quality-oriented departments are merging to reduce administrative waste and streamline patient care. As a result, case management, social work, risk management, utilization review, and even infection control are now engaged in a game of musical chairs, with professionals from each discipline circling warily, hoping to secure their positions in a changing health care environment. The question is, who’ll be left standing when the music stops?
At many hospitals, it will be utilization review (UR), which some experts consider a dying discipline that will be absorbed entirely by case management.
"In three to five years, I don’t think there’s going to be UR as we know it today," says Bonnie Sturges, RN, BSN, an accreditation reviewer with the Utilization Review Accreditation Commission (URAC) in Washington, DC. "There will be case management. With TQM [total quality management] coming into place, it seems like everything is starting to fall under that same umbrella. And case management is probably the neatest way of doing UR, because [case managers] are really looking out for the patients and getting them home or getting them to the appropriate setting."
Garry Carneal, president of URAC, notes that UR has already evolved away from its original mandate. "What was known as utilization review in the early 1990s was more of a straightforward review of the clinical criteria to determine what’s medically necessary and appropriate," he says. "That’s evolving into utilization management, which contains an overlay of quality assurance, and finally into case management. Case management involves a more fluid kind of decision- making process. There’s just more flexibility built in, a more global approach to things."
Case management’s absorption of UR has been made almost inevitable by the changing nature of health care reimbursement, adds Larry Strassner, MS, RN, manager of health care consulting at Arthur Andersen LLP in Baltimore and former director of critical paths at The Johns Hopkins Hospital in Baltimore. Strassner notes that UR was created in the 1980s in response to the diagnosis-related group (DRG) coding system, whereas case management grew up with managed care. Now, as more managed care markets become capitated, it’s imperative that case managers take a more active role in the business side of health care.
"The more you become fully capitated, the more risk shifts to the hospitals," Strassner says. "As that risk shifts, it’s up to the providers to manage the patient well. Not that the payer ignores or isn’t interested in utilization review, but it’s really up to the provider to do it. And that responsibility is likely to fall to the case manager, who’s clinically competent, who’s caring for the patient, knows what is appropriate and not appropriate for a particular guideline, and has already gained the trust of the physicians and others working with the patient."
Data must have clinical focus
At Community Hospital of San Bernardino (CA), Sandra L. LaRusso, RN, MA, ARM, director of case management, has already brought risk management, utilization, social work, and infection control into her case management department. (See related story on Community Hospital, p. 5.) One of the main reasons she did so, she says, was the difficulty of achieving effective communication between the different departments. "Communication is not very good when those areas are not integrated in some way," she says. "And it doesn’t matter whether the organization is large or small. In a large organization, if the functions aren’t coordinated in some way, there’s just so many layers to go through that communication is difficult. In a small organization, it’s so politically intense that communication is difficult to get where it needs to go."
Other experts agree that case managers often don’t have timely access to aggregate data from utilization review in a non-integrated system. "If you’re going to have a fragmented approach and have somebody doing the centralization of the data, how does that data get reported so the trends or patterns can be appropriately addressed?" asks Judy Homa-Lowry, RN, BS, CPHQ, a health care consultant based in Canton, MI, and consulting editor of Hospital Case Management.
Homa-Lowry adds that UR data tend to be "more case-by-case reimbursement looking at utilization trends in terms of cost containment and not necessarily always looking at appropriateness of utilization." Because such data sometimes lack a clinical component, they "may not be totally reflective of what’s happening in the organization."
Placing utilization under the control of case management helps hospitals better analyze financial data in terms of clinical realities, Sturges adds. "They’re collecting medical information," she says. "It’s clinical information. And someone who has not had much clinical experience may have a harder time getting some kind of interpretation out of that. Especially now that we’re seeing quality taking over everything."
LaRusso stresses that the primary role of case management has always been the effective coordination of care. Because case managers understand disease processes, they’re better able to make accurate predictions and assumptions than someone with a less extensive clinical background. "[The case manager] is the most flexible person, and my organization, like many others, is moving toward the person who’s the most flexible," she says. (For sample job description from Community Hospital, see p. 2; for performance standards, see p. 3.)
Build financial credibility
While staff who lack clinical training may continue to play some role in utilization management, it’s not likely to go beyond administrative functions, adds Sturges. "It’s possible for a [non-clinically trained] person to do these reviews as long as everything is scripted along a decision path so they don’t have to make a judgement based on clinical background," she says. "But because case management appears to be driving the market now, I think that it’s going to be a novelty to see someone in UR who does not have a clinical background."
Strassner contends that such staff aren’t effective decision makers because physicians respect them less. Because UR nurses often have only reviewed medical records and applied what was in them against written criteria, "physicians don’t see them as clinically competent and don’t trust in their ability to coordinate care."
Case managers, on the other hand, are better equipped to challenge physicians and other clinicians in a way that is non-threatening "but that also makes sense clinically," Strassner says. "They’re able to say, You know, we already received a CT scan the other day. Do we really need to do this MRI?’ And they’re able to talk about the results of the CT scan, and what’s important vs. what’s not important."
More job changes ahead
The case manager’s role is likely to change in other ways as well, Strassner adds. Because of the increasing focus on disease management, hospital-based case managers will be responsible for managing the patient’s care across the continuum. That may mean acting as a liaison with an outpatient case manager or the payer’s case manager. "Clearly, for hospital case managers, the clinical competency is of utmost importance," Strassner says. "Because they’ll take on a lot more of the clinical management of the patient."
Even so, case managers face a number of challenges as they become more involved in utilization management. In some hospitals, case managers have had solely clinical responsibilities and have had a difficult time adjusting to the business aspects of health care. To ease the transition, Strassner recommends featuring financial issues prominently in the initial orientation, including utilization review. "That includes issues with your payers who they are and what criteria they’re using," he says. "It also involves looking at physician profiles or case management report cards, which clinicians aren’t used to looking at and applying in managing patient care."
It’s important to stress that analyzing data is a significant part of managing the patient, Strassner says. "And it’s not just the clinical data now; it’s also the financial data." Strassner advises setting benchmarks for what you’re hoping to achieve, and then establishing reports that help you monitor progress toward your goals. "Then the case managers will be responsible for taking and analyzing the data, then bringing it back to an interdisciplinary team to say, Here’s what the data looks like. Where do you think we can make improvements?’"
Another challenge is that, although case managers may have clinical credibility, they’ll have to build credibility with others in the organization regarding their financial judgement, LaRusso says. "Case managers aren’t readily accepted in their role as a businessperson. They find themselves in unknown territory as far as the rest of the organization is concerned, and so they’re finding that they’re having to build their credibility all over again."
LaRusso adds that when departments are consolidated, it’s not just the case managers who have to adjust to their new responsibilities. "It’s been my experience that the change within the department has gone much faster," she says. "The external change getting the rest of the organization to see my staff in their different roles is taking a lot longer. They still keep trying to use them in their old roles. And they don’t understand that their job description looks totally different from when they were a social worker as part of a social services department, or a registered nurse as part of a utilization review department."
For more information about utilization and case management, contact the following:
Garry Carneal, president, or Bonnie Sturges, RN, BSN, accreditation reviewer, Utilization Review Accreditation Commission, 1130 Connecticut Ave. NW, Suite 450, Washington, DC 20036. Telephone: (202) 296-0120.
Judy Homa-Lowry, RN, BS, CPHQ, health care consultant, 7245 Provincial Court, Suite 100, Canton, MI 48187. Telephone: (313) 459-9333.
Larry Strassner, MS, RN, manager of health care consulting, Arthur Andersen LLP, 120 E. Baltimore St., Baltimore, MD 21202. Telephone: (410) 234-3894.
Sandra L. LaRusso, RN, MA, ARM, director of case management, Community Hospital of San Bernardino, 1805 Medical Center Dr., San Bernardino, CA 92411. Telephone: (909) 887-6333.
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