how does the him review over-utilization of healthcare services for your medicare population

What is a utilization review in healthcare?

How is healthcare utilization measured?

What are the steps of the utilization review process?

What are some of the factors influencing utilization of the healthcare services?

Why is utilization important in healthcare?

What is health services Utilisation?

What does a utilization reviewer do?

What are the three steps in medical necessity and utilization review?

What are the skills needed to perform utilization review?

What are the factors influencing hospital utilization?

What are the factors affecting the utilization of health care services in Nigeria?

What has been the trend in the utilization of hospital based services what factors help to account for this trend?

How is health care utilization determined?

Health-care utilization is determined by the need for care, by whether people know that they need care, by whether they want to obtain care, and by whether care can be accessed. Quality is a construct separate from access and is related to the achievement of favorable outcomes associated with utilization, not to whether health-care utilization occurs at all or to difficulties in obtaining care. In theory, health-care utilization should correlate highly with the need, however defined, for services. But, some services are needed and not obtained, and others are utilized but not clearly indicated, or are indicated only after other protocols are followed (Kale et al., 2013; Kressin and Groeneveld, 2015; Lyu et al., 2017). The committee did not address various technologies and whether they might be useful for disability assessments, because data on technologies are insufficient for such assessments. For example, telehealth is not widely used throughout the country, and the medical field continues to try to determine how it can be used most effectively. However, the committee did examine national data when they were available.

How does health care utilization affect the population?

Many factors affect health-care utilization independently of need and are reflected in differences, some of which are remediable, among population groups . Some of these factors are related to biologic or environmental differences among groups, such as disproportionate residence in polluted environments, access to healthful food and adequate housing, and education associated with effective use of health care. Others are related to differences in access, such as health insurance coverage or income needed to obtain services, ease of obtaining services, and discriminatory practices of providers.

What are the dimensions of access to health care?

More recently Levesque et al. (2013)defined access to health care by presenting five dimensions of accessibility: approachability, acceptability, availability and accommodation, affordability, and appropriateness. They saw access as the opportunity to identify health-care needs; to reach, obtain, or use health-care services; and to have the need for services fulfilled. Access can be seen as a continuum: even if care is available, many factors can affect ease of access to it, for example, the availability of providers who will accept a person's insurance (including Medicaid), ease in making an appointment with a given provider, the ability of a patient to pay for care (even if a patient is insured, due to cost-sharing copayments and deductibles), and the difficulty of arranging transportation to and from healthcare facilities (AHRQ, 2010, MACPAC, 2016). Some of those issues are discussed below.

Why are there barriers to access to care?

Assuming that services are available, access to care might be impeded by other barriers. One is inadequate transportation, either because travel time is excessive, because no public transportation is available and the person does not have a car or other alternative transportation, or because the cost of transportation is prohibitive. Providers might refuse to see patients because no appointment times are open, or because they do not accept patients' insurance. Providers might be unable to communicate with patients because of language issues, or their offices might not be accessible to people with disabilities. Excessive wait times to obtain appointments or to see providers at their places of service might also deter use (MACPAC, 2016; NCHS, 2016).

How has the healthcare delivery system changed over the past few decades?

The health-care delivery system has undergone great change over the past few decades. New and improved drugs, devices, procedures, tests, and imaging machinery have changed patterns of care and sites where care is provided (NCHS, 2003). The growth of ambulatory surgery has been influenced by improvements in anesthesia and analgesia and by the development of noninvasive or minimally invasive techniques. New and improved, and less invasive, procedures are available to treat a number of previously untreatable conditions in a variety of new sites of care, or even in physicians' offices. New drugs can cure or lengthen the course of disease, although often at increased cost or increased utilization. Combinations of technologies can be more effective than individual ones, such as the combination of drugs now used to treat HIV/AIDS, combination chemotherapy for many types of cancers, and the recent creation of scanning machines that combine positron emission tomography and computed tomography or positron emission tomography and magnetic resonance imaging. As some technologies become easier to use and less expensive, as equipment becomes more transportable, and as recovery times for procedures are reduced, even complex technologies move out of hospitals and institutional settings and into ambulatory surgery centers, provider offices, outpatient facilities, imaging centers, and patients' homes and become more accessible. The average length of hospitalizations decreased with the diffusion of new technologies until 2010 and has been constant since then (NCHS, 2016).

What are the factors that influence the use of health care services?

The committee was tasked with identifying factors that influence a person's use of health-care services, including poverty and level of urbanization. This chapter will address those factors. The committee has organized the beginning of the chapter around individual and societal determinants of health-care utilization, including factors that affect the need for care, the propensity to use services, and barriers to the use of services. That is followed by a brief overview of disparities in the use of health care that have differentially affected different population groups. Finally, it concludes with a discussion of what is known about the relationship between disability status and use of health-care services.

Why can't people access health care?

People cannot access care if it does not exist in their geographic area, or if providers will not treat them because of insurance or other issues. Rural areas in particular have been identified as lacking a sufficient supply of specialty physicians and, in particular, mental health-care providers (Meit et al., 2014; Douthit et al., 2015).

How much does overutilization cost in healthcare?

Overutilization in Healthcare is a problem which has been estimated to cost in the range of hundreds of billions of US dollars every year. Despite historically spending more than double per person on healthcare than the average developed country, our outcomes have not been significantly better (1). To improve, specialty organizations publish clinical quality initiatives and practice guidelines that support consistent, focused, evidence-based care.

What is context4 healthcare?

Context4 Healthcare is constantly updating our Fraud, Waste and Abuse software. We continually monitor for emerging inappropriate utilization patterns. We use these emerging patterns, as well as information from OIG and specialty organizations, to constantly adapt and adjust our solution. With the use of the Context FWA solution, we can help you identify significant patterns that impact your unique payer environment. You can analyze and drill down on these patterns with our appropriate edits and reports. They can help you adapt quickly and avoid inappropriate overpayments due to overutilization.

What percentage of healthcare is used by older adults?

Older adults have much higher rates of health services utilization than do non-elderly persons. Although they represent about 12 percent of the U.S. population, adults ages 65 and older account for approximately 26 percent of all physician office visits (Hing et al., 2006), 35 percent of all hospital stays (Merrill and Elixhauser, 2005), 34 percent of prescriptions (Families USA, 2000), and 90 percent of nursing home use (Jones, 2002). Utilization data for several acute-care services are displayed in Table 2-3.

Why do older people have different health care needs?

Future generations of older Americans may have different health care needs because of changes in the distribution of many demographic charac teristics, including race, socioeconomic status, and geographic location, and also because of changes in personal preferences about how they care for their health and where they receive their health care services. It is difficult to make exact projections of these needs because of uncertainties regarding the effects of changes in demographics, lifestyle, and disease prevalence. Utilization patterns may also change markedly because of these effects and also because of changes in the health care marketplace and innovations in medical diagnostic and treatment modalities. While projections are difficult, one conclusion is certain—that the absolute growth in the number of older Americans will strain the current health care system if patterns of care remain the same.

Why do older people visit doctors?

On average, older adults visit physicians’ offices twice as often as do people under 65, averaging 7 office visits each year and totaling approximately 248 million visits in 2005 (NCHS, 2007). Older adults are more likely to visit a physician’s office for a chronic problem or for a pre- or post-surgery visit, but they are less likely than younger persons to seek preventive care. In 2004 the most common reasons for older adults to make office visits were all related to chronic conditions: hypertension, malignant neoplasms (i.e., cancer), diabetes, arthropathies and related disorders (i.e., problems with joints), and heart disease (Hing et al., 2006). Older adults frequently made visits to internal and family-medicine physicians, but more than half of their visits were to specialists (NCHS, 2007). Older adults also tend to visit multiple physicians. In 2003 half of Medicare patients visited between two and five different physicians, 21 percent visited six to nine physicians, and 12 percent visited ten or more different physicians (MedPAC, 2006).

How many older adults will be in the US by 2030?

Between 2005 and 2030 the population of older adults is expected to almost double, from almost 37 million to 70 million (U.S. Census Bureau, 2000), although the need for health services may not rise in direct proportion. During that time, a number of factors are likely to alter the future health status and patterns of utilization among older adults, making projections of health status and utilization uncertain. As discussed previously, health status and utilization patterns vary according to certain demographic characteristics, and the future older adult population will look somewhat different from today’s older adults ( Box 2-2 ).

How does the health of older adults affect their health?

While these improvements appear to be related in part to declines in smoking rates and better control of blood pressure (Cutler et al., 2007), the causation has not been conclusively proven. Studies also show improvements in the reported physical functioning of older adults, such as the ability to lift, carry, walk, and stoop (Freedman et al., 2002), as well as declines in limitations in instrumental activities of daily living (IADLs), such as shopping for groceries, preparing hot meals, using the telephone, taking medications, and managing money. The evidence for declines in limitations in activities of daily living (ADLs), such as eating, bathing, dressing, using the toilet, transferring (such as from bed to chair), and walking across the room is less strong (Freedman et al., 2004a). Finally, the percentage of older adults who self-report their health as “fair” or “poor” has declined (Martin et al., 2007). Despite these improvements, however, older adults still do have high rates of chronic disease and disability, particularly as compared to younger adults ( Table 2-1 ), and disease prevalence has risen as longevity has increased (Crimmins, 2004).

How will the number of people over 65 increase?

Over the coming decades, the total number of Americans ages 65 and older will increase sharply . As a result, an increasing number of older Americans will be living with illness and disability, and more care providers and resources will be required to meet their needs for health care services. In order to design effective models of care delivery and prepare a health care workforce to serve this future population, one needs to understand both the projected health status of this population and the demand for health services under the current system. Such an understanding will help identify what changes will need to be made in the health care workforce (in terms of its size, distribution, and training) to fulfill its looming charge.

What percentage of older adults are in good health?

Many older adults are actually in very good health, for example—44 percent of adults in the 65-74 age range and 35 percent of adults 75 and older report their health status to be “very good” or “excellent” (Pleis and Lethbridge-Çejku, 2007). And a sizable minority, approximately 20 percent, have no chronic illnesses (AOA, 2006; CDC and Merck Company Foundation, 2007). These healthier older adults tend to be community-dwelling individuals who require only preventive and episodic health services.

What is overuse in healthcare?

Overuse, which Chassin and Galvin defined as the provision of medical services for which the potential for harm exceeds the potential for benefit ,1is increasingly recognized around the world. Directly measuring overuse requires a definition of appropriate care, which is often challenging. In the United States, estimates of spending on overuse vary widely: conservative estimates based on direct measurement of individual services range from 6% to 8% of total health care spending,2while studies of geographic variation (an indirect measure) put the proportion of Medicare spending on overuse closer to 29%.3Around the world, overuse of some individual services may be as high as 80% of cases (see Figure 2: Overuse of Selected Services in Four Countries).4While overuse has been best documented in high-income countries (HICs), low- and middle-income countries (LMICs) are not immune, and evidence suggestive of widespread overuse is accumulating from countries and health systems as diverse as Australia,5Spain,6Israel,7Brazil,8and Iran.9Overuse can coexist with unmet health needs, particularly in LMICs.

How is overuse measured?

Overuse can be measured in a variety of ways. Overuse of a specific service can be measured directly in a population, using patient registries or medical records. This approach requires a reliable definition of appropriateness for a given service, generally using an evidence- or consensus-based guideline, or a multidisciplinary iterative panel process (e.g. the RAND Appropriateness Method) to define necessary and unnecessary use. Rates of overuse are then calculated as either the proportion of delivered services that are inappropriate or as the proportion of patients with a disorder who receive the service inappropriately. This direct measure is the most reliable indicator of overuse, and a growing body of literature, including several systematic reviews, 4,10–13have employed it. There are, however, several challenges inherent in this approach when applied to many health care interventions.12First, as discussed above, evidence for defining appropriate care is lacking in many clinical situations, precluding direct measurement of overuse of those services. Second, even if evidence is available, guidelines often lack necessary details for defining the appropriateness of care in individual patients, while iterative panel processes, which incorporate more nuance, are costly and time consuming. Electronic health records (EHR), and the development of large datasets informed by clinical information from EHRs has facilitated measurement of overuse in some contexts (e.g. the U.S. Veteran’s Affairs system26,27) and may have broader applicability in the future. However, EHRs alone are not likely to enable widespread direct measurement of overuse.

What is overuse in medical terms?

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a global problem that afflicts rich and poor countries alike. This article reviews the definition of overuse, methods for measuring overuse, harms from overuse, and the evidence for worldwide overuse of many types of services.

How many folds is regional variation in adjusted rates of total hip and knee replacement?

US:5-fold regional variation in adjusted rates of total hip and knee replacement 53

Is there a clear benefit to medical tests?

Some medical tests and treatments are of clear benefit, and some are clearly ineffective and therefore offer only net harm. There is clear underuse of effective services, and clear overuse of ineffective services. Many services fall into a more nebulous grey zone, where evidence is lacking, or the services is delivered to inappropriate patients, or to patients who are poorly informed.

What is UR in healthcare?

An effective utilization review (UR ) program can help a healthcare organization reduce denials and increase payments. U.S. hospitals are losing millions of dollars each year because of denials by health plans and government payers for acute care. But rather than continuing to take write-offs or forced reductions based on authorization issues, ...

Why do healthcare organizations need to commit to UR?

Healthcare organizations need to commit to UR to be sure that what needs to be done is getting done, within the time frame necessary to meet regulatory and insurer requirements. Compounding the issue oftentimes the person in charge of UR has either clinical or financial acumen but rarely both.

How do clinical and UR work together?

Clinical and UR staff must work together to build a case and submit it for insurer authorization in the time frames required. For example, let’s say a patient presents with only two of three medical necessity indicators for heart failure, and the insurer rejects the hospital’s request to admit the person as an inpatient. Based on other critical clinical factors, the nurse knows observation status will not suffice for this patient’s critical needs. In this case, the nurse should work with the overseeing physician and their UR counterpart to build a case for authorization of inpatient treatment, within what are often quick-turnaround insurer deadlines.

Why do hospitals need communication?

In fact, communication needs to flow across several teams (e.g., patient access, UR, patient financial services, managed care, and physician partners) for hospitals to have the best opportunity to advocate on behalf of patients and be paid accordingly and appropriately.

What happens if hospitals don't have a feedback loop?

Without a constructive feedback loop, errors and write offs will continue to be made and hospitals will continue to suffer significant revenue losses.

How long does it take to audit a hospital for UR?

Conducting an effective UR audit and analysis generally requires about three months of deep assessment. Usually, the initial assessment is followed by six weeks of UR program redesign for optimization and pilot implementation, three months of review and iterative design, and, from there, milestone measurements and continuous improvement tweaks.

What is an assessment of the UR department?

An assessment of the UR department will help determine where gaps exist and make way for interventions such as UR training modules and recurring update touch points for clinical staff.

Why is utilization management controversial?

Physicians have been outspoken critics of utilization management because it has limited their clinical autonomy and has contributed to an intolerable administrative burden.

How does UR affect inpatient care?

Instead, UR more closely managed patients' length of stay through concurrent review after patients were hospitalized. The impact of UR on inpatient care was greatest for mental health patients ( 78 ). Whereas mental health patients, including patients with a diagnosis related to substance abuse, represented only 5% of the study population, they accounted for over 50% of the total days saved due to UR. In contrast, obstetric admissions represented almost 40% of the total number of cases reviewed yet they accounted for a trivial (3%) portion of the reduction in hospital days. The fact that obstetric admissions are approved 100% of the time and almost always have short hospital stays, even for cesarean section cases, explains the small proportionate reduction in hospital days. This finding calls into question the common UR approach of using pre-admission review to certify the need for hospitalization when, as in the case of obstetric care, the clinical need for hospitalization is obvious. Further, the volume of such reviews adds significantly to the administrative burden imposed by UR on the health care system.

How does UR affect quality?

As part of this same series of UR studies, Wickizer & Lessler examined the effects of UR on quality, as measured by early readmission rates. Three separate analyses performed on different patient groups, mental health patients ( 77 ), pediatric patients ( 79 ), and cardiovascular patients ( 33 ), generated consistent findings showing that reduction in requested length of stay resulting from UR was associated with increased relative risk of readmission within 60 days. This effect was especially pronounced for cardiovascular patients who had a surgical procedure for which the requested length of stay was reduced by two or more days. Such patients were 2.7 times as likely to be readmitted within 60 days as patients having no reduction in requested length of stay ( 33 ). While the increase in absolute risk of readmission associated with UR was small, these findings nevertheless raise questions about the potential effect of UR on quality for some patients.

Why are methods for determining appropriateness and necessity valid and reliable?

Methods for determining appropriateness and necessity must be valid and reliable if they are to promote efficient clinical care and gain the trust of the professional medical community and patients. The ultimate reliability and validity of decisions rendered through utilization review depend on the nature of UR criteria and the process of applying those criteria to the specific clinical circumstances of patients.

What is utilization management?

Utilization management (UM) represents a broad array of techniques designed to influence the consumption of health care services, usually with the objective of promoting cost containment . During the past 20 years, UM has gained acceptance as an approach to cost containment and has become a prominent fixture of the U.S. health care system. Managed care plans, public and private payers of health care services, insurance carriers, and hospitals have used UM in one form or another to control health care utilization and contain costs ( 12, 29, 42, 73 ). Even physician medical groups—often the target of UM—have relied on UM techniques to control the volume of services when they have been placed at financial risk through managed care risk contracts ( 29 ). Evaluations of UM have generated mixed findings, with some studies showing reductions in utilization and costs and others showing little effect. Despite its widespread use, UM has engendered debate and controversy. Physicians have been outspoken critics of UM because it has eroded their clinical autonomy. UM has also been criticized for its role in contributing to the mountain of paperwork that now burdens the health care system. Insurance carriers, third-party payers, and health plans have defended the use of UM as an imperfect, but necessary, practice that is needed to reduce consumption of unnecessary or inappropriate health care services and thereby contain health care costs.

How long did the HMO trial last?

The duration of the trial was 12 months. The primary outcome, hemoglobin A 1c values at 12 months, decreased significantly for the case management group relative to the controls. Self-reported health status measures also improved for the case management group, but the study found no differences in other outcomes, including blood pressure, body weight, medication type or dose, or lipids.

What is the purpose of UM review?

The purpose of this review is to: ( a) describe the key features and effects of UM; ( b) critically examine the process of utilization review , arguably the most controversial and invasive feature of UM; and ( c) discuss the future role for UM in the twenty-first century. The health care system is clearly in transition, moving away from restrictive managed care arrangements and toward more flexible consumer-oriented delivery models. The UM program of tomorrow is likely to be quite different from the UM program of today. This review provides an opportunity to consider the purpose of UM and how it might best meet the future needs of the health care system.