I have a confession to make. I have done a utilization review. This means that requests for treatment, including medications and injections will be sent to me. Most of these reviews are for Workers’ Compensation injuries, but the situation is analogous for Medicare and private insurers. As the Exchanges get formed, they will be managed care organizations, and similar limitations. The precise mechanism depends on which is involved. The fundamental basis is evidence-based medicine, which allow us to review and assess the appropriate literature to determine which treatments or procedures are relevant to a given patient. This understanding of the literature, coupled with clinical experience and patient preference provides the basis for clinical decision making.
A problem we face is poor management of physicians. Instead of incorporating clinical experience, there is a fear of giving physicians autonomy. Treatment decision making is made in accordance with highly detailed treatment guidelines. Epidurals require documentation of radiculopathy on exam with corroboration of that radiculopathy on either MRI or electrodiagnostic studies. Don’t document all of that, you don’t get the epidural authorized. Stellate injections re worse. If you do not document either a 1.5 degree Celsius temperature increase or a rise in temperature to 34 degrees Celsius in the document you send supporting your request, you will not get authorized.
This level of detail does not help patients. It increases the cost of providing care with no improvement in care. It absolutely misreads how you manage physicians. This approach is based upon the assumption that physicians need to be micromanaged, that they cannot be trusted and that physicians, particularly those in private practice provide unneeded care just to make money, regard of the benefit to the patient. Obviously, there are bad apples in every group, including health care planners and administrators. Most physicians, however, are very self-directed and, if given goals, work very hard to achieve those goals. Remember back in college? On Friday nights, when you were going out, the premeds were studying? They haven’t changed. MemorialCare Medical Group has implicated a program of following various parameters and the physicians have enthusiastically and successfully followed them. These parameters are primarily related to primary care and there is much work to be done with showing that specialty practices provide value.
The MemorialCare experience is in the minority. Most administrators seem not to trust physicians, hence this overly detailed, productivity reducing, expensive micromanaging use of guidelines. If one is concerned that physicians in fee-for-service do provide “the right care to the right patient at the right time,” all one needs to do is to incentivize physicians to provide that care. It is not that hard. All it takes is trust. Unfortunately, we seem to be at a time when trust is secondary to control. Perhaps with the problems associated with the role out of ObamaCare, the value of trust and transparency will come forward.