While managed-care models can provide a direct path to influencing outcomes, existing practices can be reimagined to drive value. The traditional approach to utilization management (UM) is a case in point. For decades, health plans’ prior authorization (PA) processes have unintentionally frustrated physicians while offering insufficient return for health plans.Yet a PA request provides one of the only data signals of planned medical services before they are rendered—which can be incredibly valuable for enabling patient support and optimizing the impending care journey.
With a more strategic approach to PA, UM programs can influence physician care choices to reduce variations, improve outcomes, and support care coordination for chronic, costly conditions like cardiovascular disease (CVD). Instead of focusing solely on determining if an authorization request for a specific procedure meets predefined criteria for medical necessity, health plans can collaborate with physicians and patients to ensure the service requested is right for that specific patient based on their individual condition and coverage.
The complexities of cardiovascular care
Let’s look at how reimagining UM can help health plans manage the most expensive chronic condition: CVD. Nearly half of Americans have some type of CVD, a category that includes coronary heart disease, stroke, and heart failure. By 2035, annual direct and indirect health care costs for patients with CVD are likely to total more than $1 trillion.
Unnecessary variation in CVD diagnosis and treatment, exacerbated by multiple handoffs across primary and subspecialty clinicians, can drive up costs and result in suboptimal outcomes. Cardiovascular care typically involves multiple entry and reentry points, from the emergency department (ED) to primary care physicians (PCPs), cardiologists, and hospital admissions. Further, a patient’s presenting symptoms are often nonspecific, leading to a complicated decision tree as clinicians attempt to rule out other suspected conditions.
Once physicians embark on a cardiology diagnostic pathway, they might order any of several diagnostic tests depending on the setting, available clinical data, and physician expertise (ie, a PCP vs an ED physician). As a result, clinicians often use more tests than necessary to reach a diagnosis.
After a patient is referred to a cardiologist, variable adoption of new consensus guidelines can lead to nonconformity of care. In 2021, the American College of Cardiology (ACC) and the American Heart Association (AHA) co-issued new guidelines for the evaluation and diagnosis of chest pain and coronary artery revascularization. Coronary CT angiography (CCTA) is now the favored diagnostic test for patients without known coronary artery disease (CAD) who are younger than 65 and experiencing stable chest pain. The new guidance recommends reserving revascularization for those with refractory symptoms or populations with high-risk coronary anatomy.
Managing a patient’s care path
As long as legacy UM programs focus on managing individual Current Procedural Terminology codes and procedures, rather than the entire cardiac care journey, health plans will be limited in their ability to manage the cost and value of CVD care. Supporting the patient’s entire health care journey—across physicians, locations, and episodes of care—is crucial for improving outcomes, especially for lifelong chronic conditions.
An intelligent UM platform can leverage relevant, patient-specific clinical data to better understand a PA request within the context of the patient’s care history. This comprehensive view of the patient’s care trajectory allows health plans to effectively manage a condition, rather than one disconnected service at a time. Using historical clinical, claims, and outcomes data, an intelligent UM platform can create condition-specific cardiology care paths that guide the patient’s care journey from presentation through postoperative care and long-term management.
Using artificial intelligence and machine learning, an intelligent UM platform can help health plans and physicians speed the time to an accurate diagnosis, facilitate comprehensive care management services, and improve the selection of invasive and interventional procedures. The key is evidence-based clinical intelligence that reduces care variations, generates medical cost savings, and improves care quality.
Speeding the time to diagnosis
When physicians are offered automated, evidence-based clinical guidance at the point of authorization, they are more likely to select high-value tests and treatments. For example, a smart UM platform might prompt a physician who is entering a PA request for a myocardial perfusion imaging test/single-photon emission CT to select a CCTA instead. For a patient with a low pre-test probability of CAD, the platform might first recommend a routine treadmill test or a coronary calcium-score screening scan, as suggested in the 2021 ACC/AHA guidelines.
By prompting clinicians to select the appropriate evidence-based test, as recommended by national medical societies such as the ACC, a smart UM platform removes the guesswork involved in PA while assuring providers that evidence-based modalities will be immediately approved by the health plan. This type of proactive UM speeds the diagnostic process and decreases unnecessary variation in the number and sequencing of ordered tests.
Pinpointing the optimal procedure
Similarly, an intelligent UM platform can deliver in-platform recommendations to guide the selection of surgical evaluations or procedures. When a patient requires an invasive cardiac evaluation or an interventional procedure, an intelligent UM platform can help physicians avoid unnecessarily aggressive treatment by requesting proper documentation of the indications.
By analyzing the patient’s calculated risk score and accounting for their previous health care history, the platform can deliver recommendations for a procedure that meets widely accepted clinical criteria (such as national medical society guidelines) and appropriate use criteria. Further, by recognizing high-risk patients, the platform can identify when a patient is a good candidate for moving directly to procedures or surgical intervention. This enables physicians to skip more conservative care to immediately alleviate a patient’s symptoms or reduce the likelihood of cardiovascular events (spontaneous myocardial infarctions [MIs], unplanned urgent revascularizations, or cardiac death).
Enabling whole-person care management
Patients with CVD often need to make significant long-term changes to their lifestyle and require prolonged support to avoid progressive clinical interventions. An intelligent UM platform can connect patients to available resources, such as a nutritionist, a gym membership, the ACC CardioSmart program, and/or mental health support.
Many plans have invested heavily in such care management programs but have difficulty enrolling patients in the appropriate service. Partnering with an intelligent UM platform can help health plans realize a better return on their investments by identifying at-risk patients with CVD who need targeted resources. For example, patients who have experienced an MI should benefit from being enrolled in a cardiac rehabilitation program to improve their cardiovascular health.
Facilitating care coordination
When appropriate, an intelligent UM platform can suggest a bundled authorization for every service related to a particular episode of care. For example, a cardiologist requesting a coronary stent might also order blood thinners for postprocedural care. Consolidating multiple authorizations for a single episode of care saves health plans and providers time and expense.
Bundled authorizations can also activate communication protocols to ensure that procedure data, prescribed therapies, and postoperative care plan directives are shared with the patient’s PCP. By facilitating seamless care coordination, an intelligent UM platform can encourage PCP follow-up, improve medication adherence, and support proactive care management practices. Surfacing actionable data to clinicians in real time, when they are working on a patient’s case, can reduce postacute readmissions and promote a higher standard of care for patients living with CVD.
CVD is likely to remain the most expensive long-term condition for health payers to manage. Adopting an intelligent UM platform that drives the use of evidence-based medical guidelines will increase the value of cardiac care across a health plan’s membership. By enabling optimal care paths for each patient, health plans can achieve the ultimate goal: better clinical outcomes at a lower overall cost.