Utilization Management Programs Promoting Patient Safety

April 11, 2016

The evolution of utilization management (UM) interventions continue to open up new ways to promote best practices.  To that end, many health plans, care management organizations and other sponsors of UM programs have begun to focus on promoting emerging “patient safety” protocols even if these add to the over-all costs of paying for insurance.

A recent example of this quality-based approach comes from United HealthCare (UHC).  After patient safety concerns were raised over the use of power morcellators for vaginal hysterectomies, UHC implemented a new prior authorization requirement for all hysterectomies except those performed vaginally on an outpatient basis.

As reported in MedScape:

“By creating this restriction, the (UHC) has joined the backlash against the use of laparoscopic power morcellators that have been shown to disperse undiagnosed uterine cancer in abdominal cavities. The devices shred tissues so they can be removed piecemeal through laparoscopic incisions…The need for prior authorization extends to abdominal and laparoscopic hysterectomies, and vaginal procedures performed with a laparoscope. Without a prior authorization, UnitedHealth will automatically deny a claim for reimbursement.”

This practice allowed UHC to be better aligned with a recent position statement issued by the American Congress of Obstetricians and Gynecologists (ACOG).  As highlighted by the ACOG’sCommittee on Gynecologic Practice:

“Hysterectomies are performed vaginally, abdominally, or with laparoscopic or robotic assistance. When choosing the route and method of hysterectomy, the physician should take into consideration how the procedure may be performed most safely and cost-effectively to fulfill the medical needs of the patient. Evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy.”

This is a prime of example of how the UM system can be used to promote emerging trends in evidenced-based care and reduce patient harm. UM review criteria and pre-authorization requirements can be used as an effective and more timely way to implement better clinical interventions that are identified by the specialty medical societies, clinical trials, academic research findings and other sources.

Stay tuned as we continue to report on the key issues surrounding Utilization Management trends and other regulatory matters of interest.

The views expressed in this post do not necessarily reflect the official policy, position, or opinions of RegQuest. This update is provided for informational purposes. Please consult with an attorney regarding any legal matters discussed herein and/or a clinical expert regarding any health-related matters.