Tag Archives: Utilization Management

Utilization Management is Different in Corrections

This is an important fact that I have learned from many years working in prisons and jails: Most correctional practitioners do not understand how Utilization Management in a prison system works. They misunderstand what the goal of the UM process is. They misunderstand the process of submitting requests. And they misunderstand how decisions are made. It took me a full three years of working in a prison system before I wrapped my head around how UM was supposed to function. This is because UM within a correctional system is fundamentally different than UM in the outside world and also new incoming correctional practitioners are not taught how prison Utilization Management works or how to make UM requests properly.

To show how a prison is different than Utilization Management in a typical Health Maintenance Organization (HMO) in the outside world, let’s say that I am a primary care practitioner in the community who wants to order an MRI on one of my patients. As we all know from long experience, I can’t just order the MRI. I have to get it pre-authorized. To do that, I have to submit paperwork to the patient’s insurance company explaining why I want to do the procedure. Someone will review my request, but I will have no idea who this person is or what their qualifications are. The reviewer could be a physician, or it could be a nurse referring to UM guidelines.  I just don’t know and never will. Whoever that person is, they will either approve payment for the procedure or deny it.

Notice several important things about this interaction: Continue reading

Bad Medicine is Expensive!

In the last JailMedicine post, I introduced the subject of Utilization Management (UM) in Corrections. To some, Utilization Management has earned the reputation of being too focused on money and not enough focused on patients. But after I had been doing UM for awhile, I had an important insight that changed the way I thought about Utilization Management and (I believe) made my own efforts at UM much more effective.

That key insight is this: That which is expensive in medical practice is bad medicine. The way to control costs in medicine is to reduce or eliminate bad medical practice. Cost containment is simply a happy byproduct of this endeavor. When UM physician advisors work with primary care practitioners, the conversation should center around best medical practice, not money.

It is this simple: Good medicine is cost effective. Bad medicine is expensive. Continue reading

Controlling Health Care Costs: Utilization Management

Consider two people standing outside of a grocery store.

Person one is told: “Here is $200.00 for groceries for one month. You may buy any food you wish—but you may not spend more than this $200.00. So, make your purchases wisely. We are going to watch carefully to make sure that you do not exceed $200.00.”

The second person is told: “There is no limit on how much you spend on groceries in the next month. You may spend as much as you wish! And you may come back as often as you like. There are no limits. In fact, no one is even going to pay attention to what you buy!”

Which person do you think is more likely to walk out of the store with the most expensive cut of steak?
Which person is more likely to pay attention to prices and sales?
Which one do you think is more likely to buy food that they will never eat?

This scenario is very like the difference in health care spending within your average state prison system and the medical community at large. Continue reading