Hi, everyone. This is Lucas Voss with Becker's
Healthcare. Thanks so much for tuning in to
the Becker's Healthcare podcast series. Very excited to
talk about today utilization
management
that works, story strategies,
and what's next.
And I'm also very excited to be joined
by Chad Kersting, business development director,
eviCore by Evernorth, and doctor Eric Gracious, national
physician executive also of eviCore by Evernorth.
And it's great to have you both on,
and I wanna start with introductions,
to get us started here.
Doctor Gracious, why don't you kick us off?
Thanks, Lucas, and I appreciate the warm welcome.
As you said, I'm Eric Gracious. I'm
currently national physician executive for medical benefit services
at Epicor by Eber North. I'm a pediatric
hematologist oncologist by background, as well as a
general pediatrician, and
practiced for a number of years before jumping
into the utilization management business about twelve years
ago. And I've worn a number of different
hats over time from patient care to research
to teaching,
and, again, most recently in
utilization management.
And,
it's a complex issue, and I'm looking forward
to digging into it with you today.
Yeah. Absolutely. Excited to have you on. Chad,
we'll kick it over to you.
Thanks. Chad Kersting. I've been with eviCore by
Evernorth for,
going on my tenth year now.
My background is in consumer behavior,
influencing consumer behavior, changing consumer behavior.
And, that is the division I started with
at eviCore and have been able to
expand,
that role and and really,
how can we bring more of that consumerism
and education
and things that eviCore was doing on the
side,
years ago to be more of a focus
and and how can we help people? So
beyond utilization management. So looking forward to having
a conversation today.
Yeah. Absolutely. It's exciting to bring both of
your expertise together for this conversation.
It's it's very it's great opportunity.
And I wanna start with doctor Gratias. Utilization
management, we'll refer to as a as throughout
the conversation just to make it a little
bit shorter here, often gets boiled down to
prior authorization.
What do you see as the most misunderstood
or underappreciated
aspects of today?
Well, Lucas, thanks for the question. You I
mean, you you really nailed it with that
with that lead in. A lot of people
view
utilization management and prior authorization
as the same thing versus interchangeable terms.
And
really, prior authorization is one tool that's used
to manage utilization. So
utilization management is really
simply making sure that
a patient gets all of the health care
that they need and none of the health
care that they don't.
Mhmm. So that includes multiple
multiple different types of utilization management.
The most common is addressing what we would
call over utilization,
which is when patients are receiving
health care services that aren't going to benefit
them in any way at all.
And
prior authorization has historically been used to address
overutilization.
And overutilization
management has gotten the the biggest
component of the attention, which is why the
terms are interchangeable.
But what people don't recognize
is that effective utilization management also addresses misutilization,
meaning that a person needs health care services,
but the the health care services that are
most likely to help them are maybe slightly
different
than the ones that are being proposed.
And so a great example would be someone
who
their physician has ordered a CT
of their head to evaluate,
something like a headache. But when you look
at evidence based medicine and apply it to
that patient for the reasons
that you're looking
at their head and their age and their
other symptoms and things, an MRI would be
a better study. So utilization management will actually
connect with that provider and talk through the
evidence and often result in a change in
plan to that alternate study, which is gonna
be better for the patient.
And then the a bigger component, and,
you know, it's where Chad and I are
gonna spend a little bit more focused today
is on underutilization
and which is also part of utilization management.
And this is something that actually quite a
lot of
people in health care are engaged in, and
that's addressing services that people aren't using as
much as they should. So a really common
example there
would be routine vaccination
or cancer screen
or something that we know
can drive benefits.
But people, for a variety of reasons,
don't use as often as is recommended.
And so a lot of hospitals and physician
groups
are actually involved in this part of utilization
management or the guys of names like gap
and care closure
or care coordination.
And so when you think about utilization management
more holistically,
it really encompasses addressing all of those facets
of inappropriate utilization.
And prior authorization is just one of many
tools we have, which is a workflow processes,
and it involves
getting approval for to proceed with the services
before
leaping in, to the service delivery.
Yeah. And you've touched on this a little
bit, and I wanna come back to it.
This is sort of a a a follow-up
to this as well. So what do we
need to do to shift this? What are
the shifts that are needed to then improve
this process to better serve clinicians and patients?
That's a great that's a great question. So
there's a number of kind of core principles
that that you'll hear about out there in
the world. So one is just broadening understanding.
And when a kid will understand what utilization
is supposed to be and that it is
intended to be a collaborative effort.
And this should be something where
all the involved parties are are shooting for
the same goal, which is the optimal health
for the patient that's under discussion.
I think we need more transparency
around
what the gaps in care are, what the
utilization needs are for this person, and what
are the sources of evidence,
that are that are used and necessary
to to help determine that.
And you can only get there through through
better information sharing. So there's a lot of
efforts around
you hear the word interoperability
out there, which is essentially just a technical
term for being able to more easily share
clinical information or other important information about a
particular patient
through electronic means and more in real time.
So there's not this back and forth of
phone calls and faxes and
and other things. And then, you know, the
the most meaningful thing that we could do
to really shift that focus
would be to move the workflow
further upstream
so that
you know, right now, a lot of utilization
management processes come in after a physician and
a patient have discussed a course of action
and come to a decision on how they
wanna move forward
with sometimes without the the benefit of some
of those evidence based
guidelines being necessary at the point of care
when that decision is being made. So when
you start your workflow after that that thoughtful
process has occurred,
you've got an entity who's already a little
bit on the defensive because they feel like
they're defending a decision they've already come to
in good faith.
And if we could be further upstream and
we were be a technical integration into the
workflow,
of that electronic health record,
you know, and those decision aids around some
of the evidence were there in EHR at
the point of care, and we're enabling some
of those discussions
between the physician and the patient.
The combination of that transparency and that technical
integration of being further upstream.
If we could somehow, you know, accomplish those
at scale overnight, the whole discussion around utilization
management would change.
You know, we've certainly seen that in pockets
where we've had, you know, one off opportunities
to connect at that level,
with folks that does change the conversation.
And all of a sudden, this process is
viewed as a support rather than a barrier.
Yeah. It's a more active a more proactive
approach really moving from reactive to proactive, which
I think is so key.
You've touched a little bit on underutilization
as sort of one of the primary pieces,
and you've mentioned an example there. And I
wanted to come back to that. So this
is, of course, talking about members not accessing
the care they need.
Can you walk us through an example where
that was effectively addressed and changed and and
what organizations
should really take
away from it?
Well, sure. So I'll give you one where
we we leveraged one of our own workflows.
And and and again, Chad will go
into some of this as well. But, you
know, we have one of our underutilization
programs involves closing gaps in cancer screening,
where we have,
patients that we know are overdue
for
their breast cancer screening like mammography.
And
we have, we have the ability to monitor,
our overall systems. When we when we receive
a prior authorization request, for example, or again,
Louxter radiology is an example of radiology study,
and that comes in as we're about to
issue an approval for that study,
the system will run a query and say,
oh, this patient is on our list of
people who are overdue for our mammography. And
that outreach call will be transferred from our
normal outreach unit to our preventive care team
who will call that person
and say, hey. We've just wanna let you
know that your your MRI has been approved,
and I hope your hope your shoulder feels
better and everything goes well with that. But,
hey. While while I got you on the
phone, it looks like you're overdue for your
mammography.
You know? And I know you're in your
shoulder taken care of right now, but certainly
while we got you here, is there anything
we can do to kinda help you get
that closed? And
and, you know, and then the person can
say, well, you know, gosh. I have. I've
just been so busy, and
and we're able to leverage, the network of
radiology
facilities in their area. We can go ahead
and get the study scheduled for them.
Then we stay with them and follow-up to
make sure that it was done and they
got their results. If there was follow-up care,
we help connect them to that.
And just by kind of leveraging that existing
connection,
we already had where the the person was
already expecting to hear from us and then
taking advantage of that moment where we've got
them engaged on the phone just to try
to see what else we can do to
help help them, you know, navigate their care
and taking the time to actually solve it
for them in the first call.
That's an example that we we were helped
to close a gap in care for that
for that woman,
and that wouldn't have existed
if there wasn't a prior authorization process in
place for her.
So the change that really made a difference
here, you've touched on it before too, was
the shift to that more proactive approach. Correct?
Correct. It was the it was the combination
of being proactive.
It was just taking the time to stay
on the call with her and take the
extra time to, you know, check her, check
where she lived and see who was available
and talk to her about her calendar and
get it all scheduled.
But, also, I think piggybacking
on
a communication channel they were expecting to engage
with, which is where we have more success
than a historic approach of a more of
a cold call.
Because, you know, we we've all been,
you know, bombarded by robocalls and spans and
other things. So peep you know, you know,
a lot of people just don't pick up
the phone and answer when they get a
call from a random number they're not expecting.
So I think it's the hook of being
leveraging that communication that we we already have
in place with them and then taking the
extra time while we've got them and using
that moment to help move their care forward.
Yeah. Absolutely.
Chad, this is where I wanna bring you
in and and your expertise
specifically around the consumer,
as well. We talked about the proactivity, and
there is, you know, an increased focus on
maintaining health through preventative and proactive care. We
certainly know that as opposed to just treating.
How is that shift playing out within
and what's enabling it, and and what are
you seeing in terms of scalability across US
Health Care? What does it look like?
So,
you know, I think that doctor Graces brings
up, you know, points out one thing that
we do really well or and sort of
changed that that thought process of
is just being yes or no, but being
a little more collaborative.
But but really, it's it's bringing that patient
into the conversation and
and understanding what's going on with that person,
having that conversation with that person to identify
the barrier.
And utilization management really allows us to do
that at a much higher touch point or
contact level than we would be able to
do if we didn't have it and what
most other vendors and health plans have the
issues with, and that is the contact. You
know, doctor Gracious
touched on it, and that is if someone's
expecting they go to the doctor, the doctor
says you're gonna need to have an MRI
or or a CT scan on your knee.
They've told them they need an authorization. So
now that person knows,
that that's the next step. So when their
health plan shows up on the caller ID
an hour later,
they answer the phone. Or when we text,
let them know we have an update about
that authorization that drives that inbound phone call.
So that interaction,
interaction with the patients and and
really treating them like a like a person,
I think is what what's what's a little
different than what you when you think about
in the past. And and having that under,
that it's that
conversation to understand what's going on with them
allows us to,
uncover what that barrier might be, how how
they've been affected,
whether it's they can't take time off work
to get certain things done, to go to
their wellness visit or get their mammogram,
or they're waiting two months to see their
PCP because,
primary care physicians are in a shortage and
they didn't know they had virtual benefits. So
just overcoming that health care illiteracy.
And where I see this playing out in
health care is especially as we get more
virtual offerings,
as we make it easier to interact with
patients and customers
and members
via either
some of those apps that are out there
where we're able to have those two way
conversations or or two way text conversations that
that we utilize. But I think you'll see
it utilized more and more as,
utilizing that that capability more and more of
actually interacting with the person to understand what's
going on in their lives more than just
case management,
I think is what's different and where where
we're headed.
Yeah. And I think it speaks to the
fact that, again, we're looking for personalized experiences,
right, in our day to day lives. We're
looking for that support that's customized
to us, more of that consumer experience.
I'm really curious to see you've touched on
this a little bit. How do you see
this trend evolve over the next five year?
What's going to happen here, especially when you're
looking at at
I mean, I think one of the things
that we've already started to do, and, again,
doctor Gracious touched on it, earlier, and that
is, that that person comes in or enters
a health care journey.
Knowing what else that person is due for
or what else is going on in that
person's life
as EMRs get more and more connected or
as
even, we're able to collect more of the
results from the scams to know,
what were the results. And then being able
to pair that up with either other authorizations
that we've done
or if it's Evernorth
and ESI, what drugs are they on? And
we get a cardiovascular
request come in, and we can see they're
taking this drug, just this drug, this drug,
and this drug. They've had this pre auth
pre auth and pre auth. Now they're asking
for this. Where is this person headed? What
does this person look like five years ago?
What do they look like now? And being
able to predict that and address certain things
ahead of time, or are they working with
the right providers? Are they you know, what
vendors are out there, either the services that
we offer?
By looking at the data and seeing what's
going on with that patient, are they working
with the the the right groups in the
to to effectively treat their condition?
And being able to provide clinical decision support
to their providers and and looking at things
holistically.
Because you sort of pointed out earlier that
we are in the business historically
of treating illness.
People enter the health care system when they're
already sick.
But if we have the data on that
person,
we can pretty accurately predict what's coming next
for them. And being able to do that
at scale
across our book of business,
that is something that isn't very far off.
Yeah. Absolutely.
Chad and doctor Gracious, I wanna thank you
both for your insights and time today. This
is a fantastic conversation. It sounds like proactivity
is the name of the game, which is
very, very important.
We also want to thank our podcast sponsor,
eviCore by Evanorth, and you could tune in
to more podcasts from Becker's Health Care by
visiting our podcast page at beckershospitalreview.com.