Bass, Berry & Sims attorney Lindsey Fetzer provided insight for an article in HealthLeaders examining the role of utilization management (UM) in healthcare. The first article in this three-part series focused on the history of UM and its role in healthcare going forward.
“Historically, one of the primary purposes of UM has been to address overutilization of services or procedures and address the potential for waste and/or abuse of healthcare dollars,” said Lindsey.
The article examines the tension between UM’s role in reducing cost while also ensuring quality of care. Lindsey noted: “The tensions inherent to any UM process have always been the same: the goal is to balance healthcare utilization and manage cost while also expecting that the core of any UM framework be focused on whether the service is clinically appropriate/medically necessary.”
Ultimately, Lindsey defines UM’s focus as “making sure the right care is delivered at the right time, in a way that optimizes outcomes, reduces risk of adverse clinical outcomes, and considers other data points like quality and compliance” — adding that the importance of “also controlling Medicare (and other government and private program) spend so that services can continue to be offered to future generations.”
The full article, “The Many Faces of UM: A Little History,” was published by HealthLeaders on July 26 and is available online.