DorlandHealth

Editor in Chief Anne Llewellyn sits down with Dr. Dennis Robbins, MPH, an ethicist whose work touches on quality, health law and health policy, to talk about medical utilization management, denials, and the potential impact of the burgeoning area of comparative effectiveness research.

Q: What is one area of medical management you see changing as a result of health care reform efforts?

A: One of the most controversial areas of health care arises when coverage for medically necessary treatment is delayed or denied. The logic of denial is based on deflecting services or interventions that are not “medically necessary,” which is good if it protects patients against overtreatment and reduces waste. It is a negative when denying becomes an overzealous and medically unjustified crusade fueled by spurious denial criteria. Hopefully, shifting from denial-based approaches into validated, data-driven, evidence-based and comparative effectiveness standards will significantly decrease unfounded denials while ensuring the integrity of medical utilization management.

What new model do you see as a way to improve utilization of health care resources?

Reform initiatives to remove restrictive rating criteria and pre-existing illness exclusions as well as such “new” models as comparative effectiveness (CE) will play an increasingly important role in rethinking exclusions. CE is positioned to help determine which treatments are best and most appropriate. By creating a repository of evidence to determine optimal treatment among comparative options, past determinations of “medical necessity” will become more scientifically grounded and less whimsical.

Managing Editor Richard Scott sits down with Betty Pyle, RN, MS, FAACM, CMCN, CMC, the Director of Care Management at Oregon’s Salem Hospital, to talk about her department’s role in expanding the use of electronic medical records, including obstacles she has faced and tips for creating a streamlined flow.

Could you describe your role at Salem Hospital? How large is the CM department there?

I am the Director of Care Management. The department is comprised of a staff of 49 including care management, social services, and spiritual care.

Leadership staff is comprised of a director and manager of care management, two assistant managers, documentation specialist supervisor, mental health evaluator supervisor, and the resource center coordinator. Staff includes care managers, clinical documentation specialists, appeals coordinator, discharge coordinators, Medicare specialists, social workers, social counselors, mental health evaluators, and chaplains. We are unit-based and cover 10 units, Rehab, and the ED.

I understand case managers at Salem have played a role in the education of physicians regarding electronic medical record use. First, what is the importance of this area today?

Every hospital must begin implementing the electronic medical record, as this is vital to ensuring that all providers have access to the patient’s medical history to ensure that they are able to address the patient’s needs appropriately. It leads to improved patient safety, efficiency and communication, and it reduces errors. No more illegible hand-writing issues to resolve. Keeping up with technology’s advances is simply the right thing to do.

Why the urgent call for action?