How can you ensure that utilization management supports value-based care goals?

2 Involve providers and patients in UM processes

Another way to ensure that UM supports VBC goals is to involve providers and patients in the UM processes. Providers and patients are the key stakeholders in the delivery and receipt of care, and their input and feedback are essential for the success of UM and VBC. Providers should be engaged in the development, implementation, and evaluation of the UM criteria and policies, as well as the communication and education of the UM expectations and outcomes. Patients should be informed and empowered to participate in the UM decisions and actions that affect their care, such as prior authorization, concurrent review, and appeals. By involving providers and patients in the UM processes, you can ensure that UM fosters a collaborative and transparent relationship that enhances the quality and satisfaction of care.

3 Leverage data and technology for UM improvement

A third way to ensure that UM supports VBC goals is to leverage data and technology for UM improvement. Data and technology are powerful tools that can help you monitor, measure, and manage the UM performance and impact. Data can help you identify the gaps, variations, and opportunities for UM improvement, as well as the outcomes and value of UM interventions. Technology can help you automate, streamline, and standardize the UM processes, as well as integrate and share the UM information across the health care system. By leveraging data and technology for UM improvement, you can ensure that UM adapts to the changing needs and demands of the health care environment and delivers the best possible value for patients, providers, and payers.

4 Align UM incentives with VBC outcomes

A fourth way to ensure that UM supports VBC goals is to align the UM incentives with the VBC outcomes. UM incentives are the rewards and penalties that influence the behavior and performance of the UM participants, such as payers, providers, and patients. They should be designed and implemented to encourage and reinforce the UM actions and results that align with the VBC outcomes, such as quality, efficiency, and patient-centeredness. For example, payers can offer providers financial incentives for meeting the UM criteria and achieving the VBC targets, such as shared savings, bonuses, or penalties. Providers can offer patients incentives for complying with the UM recommendations and engaging in the VBC activities, such as lower copayments, discounts, or rewards. By aligning the UM incentives with the VBC outcomes, you can ensure that UM creates a win-win situation for all the UM participants and stakeholders.

5 Evaluate and update UM practices regularly

A fifth way to ensure that UM supports VBC goals is to evaluate and update the UM practices regularly. UM practices are the methods and procedures that govern the UM operations and functions. They should be reviewed and revised periodically to ensure that they are consistent, effective, and efficient, and that they reflect the current evidence, standards, and expectations of the health care system. For example, you should evaluate and update the UM criteria, policies, processes, tools, and staff regularly, based on the feedback, data, and outcomes of the UM activities and interventions. By evaluating and updating the UM practices regularly, you can ensure that UM maintains the highest level of quality and value for the health care services and resources.

6 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?