July 2004

Grant Results

SUMMARY

From 2002 to 2003, research staff at URAC studied utilization management companies to learn how they use utilization management technology and processes to identify and manage potential patient safety problems.

Utilization management, a technique widely used in the health care industry to evaluate the necessity of medical interventions, has the potential to contribute to patient safety but has not been routinely used for this purpose.

URAC is a national organization that develops standards for and accredits or certifies non-HMO health care organizations, including preferred provider organizations and self-insured plans managed by employers or third party administrators.

Key Findings
Key findings from an article in Managed Care Quarterly and a report, Patient Safety Capabilities of Utilization Management Programs, include:

  • The majority of companies interviewed address patient safety indirectly, as part of general quality management.
  • Utilization management programs are primarily designed to identify potential over-use of selected services; their approach to identifying misuse or under-use of recommended services is less systematic.
  • Many of the interviewed companies have automated protocols that trigger additional case review (e.g., a request for an extended length of stay, unexpected mortality or unexpected transfer to higher intensity care).

Key Recommendations
Industry leaders interviewed in the project called for additional research to support a direct role for utilization management in promoting patient safety. Once a clear role has been established, strategies that could be adopted to support a patient safety agenda for utilization management include:

  • Creating a culture of safety by:
    • Enhancing patient safety-related policies, procedures and training.
    • Including patient-safety criteria in clinical review standards.
    • Partnering with training and educational organizations.
  • Matching patients' health care needs with appropriate services by using guidelines for hospital referrals, case management and other services.
  • Enhancing information technology systems to support decision-making and communications.
  • Identifying high-priority clinical conditions and situations where utilization management companies can standardize assessment and data collection.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $49,988.

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THE PROBLEM

At least 44,000 people, and perhaps as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors, according to a 1999 report from the Institute of Medicine (IOM), To Err is Human: Building a Safer Health System. The IOM reports estimates the cost of these errors at between $17 and $29 billion annually.

Utilization management, a technique widely used in the health care industry to evaluate the necessity of medical interventions, has the potential to contribute to patient safety but has not been routinely used for this purpose. In 2001, URAC surveyed more than 100 utilization management companies and found that while few had defined patient safety programs, many had information systems that can flag potential patient safety problems.

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THE PROJECT

Research staff at URAC sought: to understand how utilization management companies use information technology and utilization management processes to identify and manage potential patient safety problems; and to suggest potential strategic improvements. To accomplish those goals, the project team:

  • Conducted a web-based survey of 22 utilization management companies.
  • Interviewed representatives of 14 utilization management companies about patient safety practices, contracting with Protocare Sciences to develop the interview protocol. Protocare Sciences (now Constella Health Strategies, headquartered in Durham, N.C.) is a consulting firm experienced in patient safety initiatives.
  • Convened an advisory group of industry leaders and patient safety experts to provide guidance and to review documents (see the Appendix for membership list).
  • Reviewed the commercial utilization management software used by four companies.
  • Convened a meeting of 18 industry leaders on March 20, 2003 in Washington to discuss preliminary findings and make recommendations for future utilization management involvement in patient safety.

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FINDINGS

The researchers reported their findings in Managed Care Quarterly and in a report, Patient Safety Capabilities of Utilization Management Programs (see the Bibliography for details). Key findings include:

  • The majority of companies interviewed address patient safety indirectly, as part of general quality management. Only 27 percent have a defined patient safety module in their review process.
  • Utilization management programs are primarily designed to identify potential over-use of selected services. Their approach to identifying misuse or under-use of recommended services is less systematic.
  • Many of the interviewed companies have automated protocols that trigger additional case review (i.e., a request for an extended length of stay, unexpected mortality or unexpected transfer to higher intensity care). However, there is considerable variability as to how events are clinically managed and reported.
  • Most companies have a process for grouping case experiences to monitor trends. Some 73 percent review cases through a quality improvement committee, although the criteria for selecting cases for review varies among companies.
  • Assessing treatment patterns may be a fruitful area for patient safety activities. At present, 79 percent of surveyed companies compare proposed or actual treatment to medical review guidelines. Medication review, however, is not typically considered part of utilization management, and only 9 percent of companies routinely obtain medication data.
  • Many utilization management organizations use their own in-house software or customize commercial programs. While the software programs in use support a range of patient safety practices, the variety could limit the implementation of patient safety standards across companies.

Recommendations

Industry leaders called for additional research to support a direct role for utilization management in promoting patient safety. Once a clear role has been established, strategies that could be adopted to support a patient safety agenda for utilization management include:

  • Creating a culture of safety by: enhancing patient safety-related policies, procedures and training; including patient-safety criteria in clinical review standards; and partnering with training and educational organizations.
  • Matching patients' health care needs with appropriate services by using guidelines for hospital referrals, case management and other services.
  • Enhancing information technology systems to support decision-making and communications.
  • Identifying high-priority clinical conditions and situations where utilization management companies can standardize assessment and data collection.

Communications

The project director reported findings in an article published in the fall 2003 issue of Managed Care Quarterly and in a report, Patient Safety Capabilities of Utilization Management Programs, issued by URAC. That report was distributed to study participants and to other utilization management and health care leaders and is available on the URAC Web site at www.urac.org/UM Patient Safety.pdf. The team also presented findings on a Web-enabled audio-conference in May 2003 and at the URAC Quality Summit in October 2003 in San Diego. See the Bibliography for details.

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AFTER THE GRANT

The URAC Board of Directors has designated patient safety as a focus for URAC in 2004 and has created a new advisory committee with broader representation to identify patient safety priorities and to help URAC define its role.

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GRANT DETAILS & CONTACT INFORMATION

Project

Assessment of Utilization Management Programs' Capabilities to Identify and Address Patient Safety Problems

Grantee

URAC (Washington,  DC)

  • Amount: $ 49,988
    Dates: August 2002 to June 2003
    ID#:  046096

Contact

Liza Greenberg, R.N., M.P.H.
(202) 216-9010
lgreenberg@urac.org

Web Site

http://www.urac.org

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Advisory Group

Peter C. Dandalides, M.D.
President
SHPS Healthcare Services
Scottsdale, Ariz.

Louis Diamond, M.D.
Director of Programs, National Patient Safety Foundation
Vice President and Medical Director, The MEDSTAT Group
Ann Arbor, Mich.

Kerm Henricksen, Ph.D.
Senior Staff Fellow
Agency for Healthcare Research and Quality
Center for Quality Improvement and Patient Safety
Rockville, Md.

Hart Kannegiesser, M.D.
Vice President, Network Quality Assessment
First Health
Downers Grove, Ill.

Elaine J. Power, M.P.P.
Vice President of Programs
National Quality Forum
Washington, D.C.

Alan B. Rosenberg, M.D.
Vice President, Medical Policy
Healthcare Quality Assurance
Wellpoint Health Networks
Chicago, Ill.

Allen Woolf, M.D.
Senior Vice President and National Medical Director
Intracorp
Philadelphia, Pa.

David Yalowitz, M.D.
Medical Director
Health Cost Consultants / Active Health Management
Chantilly, Va.

Consultants:
Carol Haradan
Vice President
Institute for Healthcare Improvement
Boston, Mass.

Kathy Uchida, Pharm.D.
Principal
Protocare Sciences
Santa Monica, Calif.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Greenberg L. "Capability to Promote Patient Safety in UM Organizations." Managed Care Quarterly, 11(3):1–7, Summer 2003.

Reports

Greenberg L and Schloss S. Patient Safety Capabilities of Utilization Management Programs. Washington: URAC, 2003. Also appears online.

World Wide Web Sites

www.urac.org/research. "Patient Safety Practices in Utilization Management Programs" on URAC Web site includes information on patient safety and utilization management and a list of resources. Washington: URAC.

Sponsored Workshops

"Leadership Meeting, The Role of Utilization Management in Promoting Patient Safety," March 20, 2003, Washington. Attended by 11 leaders of the utilization management industry and others involved in patient safety issues, with another seven participating by telephone.

"UM and Patient Safety Audio-Conference," May 29, 2003, via the Web. Attended by 19 representatives of utilization management companies. PowerPoint slides available from grantee.

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Report prepared by: Mary B. Geisz
Reviewed by: Karyn Feiden
Reviewed by: Molly McKaughan
Program Officer: Michael Rothman

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