BurtRepLogo02.gif (3938 bytes)

Managed Health Care
Utilization versus Retrospective Review

As managed care providers "discover" that utilization review is not only unproductive but also ineffective for cost containment they have now initiated a new journey into the unknown; the issue of retrospective review:

Retrospective review is the "Big Brother" approach to  data collection as a means of "rooting out" those health care professionals  who "habitually resort" to "needlessly expensive" or "inappropriate care" by managed care organizations.  Inherent in the retrospective review campaign is the concept of "preferred provider" referring to just who managed care has selected to direct their clients to.  The lure of implied or promised lower fees is to many with limited resources an inescapable attraction.  Are these promises kept?  Are these promises real?  Just who primarily benefits from this?  Is it the patient?  Guess again.

Collecting data is an interesting phenomenon.  Take the story of a statistician who was afraid of flying.  He always carried a bomb aboard a plane because the statistical probability of being killed aboard a plane with two bombs was nil.  Who collects the data and what data do they collect?  How do they assess the data and how meaningful are their conclusions.  Quite frankly the collection of most health care data to this point in time has reflected the computer programmer's dictum: "garbage in, garbage out."

More important than just raw data is how this information is used to judge outcomes; which are, after all, what this exercise is really all about.  Experience has shown that the most meaningful data which can be collected in the health care system must reflect:


1. Mortality and Morbidity
2. Costs
3. Patient Satisfaction

Anything less than this has little real value.  The next question relates to just who reviews and judges this information?  Peer health professionals, managed care providers and the federal government can hardly be considered unbiased and without conflicts of interest or lacking in hidden agendas.  Fortunately a single entity does exist who can judge this data with the patient's best interests being served (if presented with unbiased information provided in a comprehensible format).  This person is the patient.  The Burton ReportŪ is dedicated to the proposition that the informed patient is the best judge of the quality of  health care.

There are those who do, in fact, challenge managed care in issuing system wide guidelines as part of their effort to reduce costs.  Because of their inherent conflict of interest the dictates of managed care organizations have been taken to task for breaching their fiduciary responsibility to their clients while maintaining it for their shareholders.  Some have taken it even further and have used these data as evidence of a fraud being perpetrated on a unsuspecting public.

If there is legal merit to these claims and if the present challenges to the legality of ERISA are upheld by the courts employers, who provide health insurance to their workers, may find themselves being exposed to potential legal suit from their employees.  Clearly, if companies are held liable for the decisions of managed care organizations, they will withdraw from having a role in the health care business (something which actually makes a great deal of sense).  What makes sense is for employers to start to get serious about HSA's and becoming more respectful of their worker's personal judgment.