What it utilization review?

Every hospital has a former nurse who has the position of utilization review. This is the person who's job it is to walk around the hospital, check all the charts, and make sure the patient is sick enough, requires certain services, and is in the hospital the recommended number of days.

According to Kevin Reese, Utilization Review is defined this way:

"Hospital utilization review plans are the documentation that determine how long a patient stays in a hospital for treatment or even if the patient is admitted to a hospital for treatment. It a process aimed at providing quality patient care in a cost-effective manner, reducing hospital admissions and lengths of stay in medical facilities. It compares proposed treatment options to national averages and standards, and is used to determine whether private insurance companies or government-backed Medicaid covers hospital lengths of stay."

Also consider the following:

"Getting patients out of hospitals and into their homes or alternative treatments as quickly as possible is a cost-saving measure aimed at keeping medical costs to a minimum. As soon as a person enters the hospital, a discharge plan is put into effect in hopes of getting the person out of the facility as quickly as possible due to the normally higher medical care costs associated with hospitals. Case managers, hired by insurance companies, are often used to work out discharge plans with hospitals and physicians. Should questions arise about care after a person is discharged, a board of specialists normally will address the case and make a decision on whether care steps taken were appropriate or if the length of stay was appropriate. That decision determines insurance coverage for those procedures."

For further reading click here.

The review process is generally based on Core Measures and Intensity of Service. Core measures is defined this way:

Core measures are the things the medical staff must do when a patient is admitted under a specific core measure set: acute mycardial infarction, heart failure, pneumonia, and surgical care. Within these four sets there are 27 core measures that are based on scientifically-researched standards of care that have been shown to result in improved clinical outcomes for patients.

They have also provided a focus for the development of Clinical Pathways and Standard Orders, both of which assist in the consistent provision of optimal care to patients.

Each individual hospital uses analysis of their own core measures as a means of evaluating performance at their own institution, and as a method of improving this performance.

Intensity of Service basically means that a patient is sick enough to be admitted to the hospital. According to Medicare, Medicaid and HMOs (at least in Michigan), for a patient to meet Intensity of service certain procedures need to be ordered to prove the patient was sick enough to be admitted.

For example, for a patient admitted for pneumonia or bronchitis must have bronchodilators ordered no less than every six hours for at least 24 hours, or any of the following: an IV at greater or equal to 75cc/hour, oxygen equal to greater than 28%, IV/IM intibiotics, or three bronchodilator treatments within the first 24 hours.

So, to make sure Intensity of Service is met, or to make sure the patient meets criteria, and to make sure the hospital is meeting the core values, clinical pathways for each particular diagnoses have been created and are reviewed monthly at our regular Keystone Meetings.

Clinical pathways generally consist of one or a combination of two methods:

1. Order sets (often called protocols)
   
2. Protocols

(Note: I have a post coming soon that describes the different pathways in more detail)

According to this article by Dr. David Schechter at Family Practice Management, while this whole procedure is a hassle, the goal is noble:

• To make sure the patient really needs to be admitted (see intensity of service)
• To make sure the patient really needs acute care
• To make sure the patient "really" needs continued acute care
• To make sure the patient really needs critical care
• To make sure the patient the patient is discharged in a timely manner
• If the patient needs a diagnostic test, can it be done as an outpatient
• Could the patient's needs be better met another way.
• Did the patient really need the level of care he received?
• Could the patient have received a lower level of care?

According to Family Practice Management, "The review process may seem like nothing but a hassle to you, but it’s a necessary evil. Studies have repeatedly shown great variations in care across the country for patients who have a given diagnosis or problem. Furthermore, practicing physicians often simply aren’t aware of the options for lower-level care in their areas."

A good example here is the patient who came to the ER complaining of chest pain and who's cardiac enzymes and EKG came back normal. The patient was admitted with the diagnosis of rule out chest pain and scheduled for a stress test in the morning. Upon review, it was determined the patient could have been discharged and come in for a stress test as an outpatient.

Yet, according to Dr. Schechter, "If the patient had continued to have chest pain or unstable angina, were receiving a nitroglycerin drip or had gotten a positive enzyme test result, then the review decision would have been quite different."

For the doctor, making the right choice may be based on the following:

• Are the patient’s vital signs stable?
  
• Has a diagnosis been made?
  
• Has a treatment plan been initiated and modified, if necessary?
  
• What acute nursing needs (and other needs) are present? Can these needs be met at a lower level of care?
  
• Have you considered alternatives to hospitalization? Why are they not feasible, in your opinion
  

Options for lower level of care may be:

• A skilled nursing facility
  
• The hospital’s transitional care unit
• A hospice, for terminal patients
• A rehabilitation center, for patients needing physical, occupational or speech therapy
• A convalescent/custodial care center (nursing home)
• Home nursing visits for help with wound care, IV medications or total parenteral nutrition
• Outpatient diagnostic testing facilities
• Outpatient physical, occupational or speech therapy.

Of course, determining this may be the job of the "hospital’s discharge planner."

The Utilization Review Manager will also want to make sure the doctor documents well. For instance, Dr. Schechter notes the following:

• If patient needs to be in the hospital, the "why" should be in the chart

• If patient’s status is “observation” or “24-hour stay” rather than “admission,” this should be made clear. It will matter to some insurers.
• If the patient is unstable, it should be specified how
• Document the patient’s acute needs (e.g., “unable to stand or walk to the bathroom,” “still febrile,” “vomiting every four hours despite IV Compazine”) rather than simply stating that the patient has acute needs.
• It should be emphasized in the progress note any abnormal physical exam findings, vital signs or lab values. And make your progress notes legible."

The physician may disagree with the utilization review people from the insurance company, and if this is the case, an appeals process may take place.

Now, CMS expects a doctor will only admit a patient who needs to be admitted, and therefore expects a diagnosis and to be honest. Therefore, they do not allow for a person to review charts and tell a doctor what he should diagnose or order in order to get reimbursement.

For this reason different medical institutions will have unique names for the department and managers in charge of utilization review. For simplicity sakes, we will go by the name Quality Assurance Manager, and refer to this department as Quality Assurance (QA).

Next Wednesday I will expound the the specific jobs of the Quality Assurance Manager, and the ethics involved regarding this position.