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The Burden of Unproductive Utilization Review
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In 1987 and 1988 the Health Program at RAND, Santa Monica, California
published a series of articles on the appropriateness of a number of
medical procedures carried out between 1979 and 1982. These reports
suggested that a significant percentage of the procedures
surveyed were "unnecessary." Even though further clinical investigation
of the RAND methodology did not substantiate their conclusions this
declaration served to springboard the health care system to
justify the initiation of stringent utilization and peer review
processes and to expend significant resources in this area. By 1992
there were 350 review firms in the United States performing utilization
review on about 80% of all Americans receiving medical care.
On the other hand a 1990 survey performed by the inspector general of the
U.S. Health and Human Services Department, which reviewed 500,000
cataract operations funded by Medicare, demonstrated that the United
States government paid $13.3 million for utilization reviewers to save
$1.4 million in possibly unnecessary surgical costs. These, and other
data, made clear that utilization review was simply replacing medical
care costs with administrative costs. On November 10, 1999 UnitedHealth
Group of Minnetonka, MN (now the largest single Health Maintenance
Organization in the United States) announced that it had decided to give
physicians the final say in medical matters. Was this based on altruism?
Not a chance, it was based on their sudden discovery of the almost
decade-old observation that utilization review was economically unsound.
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In keeping with the credo of "doing poorly
that which need not be done at all" it is not infrequently the
situation, when a real M.D. does actually engage in utilization.
Unfortunately,
they are frequently not qualified, on
the basis of training or experience, to perform such a review. This
is particularly true when a generalist performs utilization review in
a specialty area. In situations such as this patient care is often denied on
the basis of being "unproven" ("experimental" or
"investigational") by the reviewer whose own coverage
decisions (experience has shown) typically reflect only non-scientific anecdotal information
which they have accepted without any mechanism for further scrutiny.
Today's "buzz" term is "evidenced based medicine" with the
assumption that real scientific data exists for every therapy; something
which is blatently not true. Actually only a small percentage of
medical practice today is justified by scientific proof. This has
given the managed care community the unique opportunity to deny covering
the majority of medical therapies if they so desire. It is unusual
for medicine to subject well established successful therapies to
scientific study. The energy and interest is clearly devoted to
pushing the horizons of treatment.Low back pain is a
common affliction and facet blocks are often recommended as part of a
conservative treatment program, and have been for over a quarter of a
century. Because this procedure, along with others, has been truly
abused by some medical practitioners for the purposes of their own
enrichment it has been termed "experimental" by some managed care
organizations. Rather than set criteria for use they have denied
legitimate, and meaningful therapy, to many patients. For example:
there are no evidenced based studies to show that appendectomy for
appendicitis is a valid procedure. This is true but we haven't yet
seen it being denied as "experimental."
How to end all this foolishness and disrespectful behavior toward
patients and physicians truly interested in the patient's welfare?
Actually it is simple. Put the patient in charge of deciding what
is reasonable for their own care. How to do this? Well, one
good approach is the
Health Savings Account. |
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