“Is utilization management only necessary because bad doctors order too many tests?” This is a common question I get when describing utilization management to people outside of the healthcare industry and the answer I give is that it is not about “bad” doctors or “good” doctors. It is about evidence-based medicine. This was especially clear to me during a recent doctor’s visit.
As an avid runner, it was only a matter of decades before I had to visit an orthopedist about some joint pain. I was mentally preparing myself for an MRI. Of course my physician’s group owns its own machine and my experience has been that over utilization is partially due to self-referral.
After a quick x-ray and twenty-minute exam, my physician prescribed some physical therapy and a follow-up visit…
Me: “That’s it? No imaging?”
MD: “If you want an MRI, I can order you one.”
Me: “Wait, no, what? I don’t need an MRI. I’ve been doing this for a long time and I’m a runner. I know what is wrong.”
My doctor was confident in the diagnosis and was comfortable with conservative therapy. However, since I asked about an MRI he took that as a request and offered an MRI.
Here was a physician, by all accounts following good evidence-based standards, who was going to schedule a high-cost procedure because a patient (with no medical training) asked if he needed an MRI. I can’t speak for the physician, but I can speculate that he was willing to order the MRI as a defensive measure since I inquired and he did not want to say “no.” Or he was willing to order the MRI because if I (or my insurance company) would pay for it, then there wasn’t much harm in one MRI.
This scenario demonstrates why utilization management and evidence-based medical guidelines are necessary, even for the most conservative physicians. When a referring physician has to demonstrate medical necessity against the guidelines, there is a mechanism in place to help a physician communicate why a procedure is unnecessary and to prevent an insurer from paying for an unnecessary procedure.
Furthermore, a utilization management program provides a framework for collecting billions of data points on patients. No matter how well a physician follows evidence-based guidelines on his own, the ability to collect and measure clinical data overtime will help these guidelines evolve and become more and more effective. Advanced algorithms and predictive models can become an incredibly powerful tool for physicians. This would make evidence-based guidelines so much more than a means for ensuring appropriate utilization, it can make these guidelines a critical quality component of a patient’s care.