What does “utilization review” actually mean?

Well, the short version is that I, and everyone else involved in the process, evaluates requests for high cost or high use procedures, medications and so on, to make sure they’re medically necessary. And let’s make sure we’re all using the same definition of “medically necessary”, too; in our world, it means “it is necessary for this patient (or, in our parlance, member) to receive this service, drug or device in order to retain their ability to function”, (or, as a corollary, they need it to prolong that ability-stuff like statins doesn’t make anything function, but it does make you live longer). To decide what is “medically necessary,” we write guidelines for the use of a whole host of things-a bunch of medications, a fair number of operations, certain types of therapy; alternatively, we use commercially available guidelines such as “InterQual”, written by corporations which do the research for us (InterQual is written by, and is a trademark of, McKesson).

There are some limits even on the “medically necessary” rule-some things are contractually excluded (in ERISA plans-plans where a large employer uses us as an administrator, but basically pays out of pocket for the health care of its employees, the employer can decide to cover, or not cover, pretty much anything they like, without regard to the laws of any given state. Some employers use this to expand the coverage they provide, but most use it to exclude some things, often things like IVF (which costs an arm and a leg), or contraception (religious organizations lke the church, for instance). Sometimes we offer a more limited contract; dental coverage can be generous or not so much, for instance. Nursing home care is capped at some number of days. And on the subject of nursing homes-for us to cover it, you need to be there recovering from something. Just because grandma can’t handle herself at home anymore, because she’s forgetful, or can’t walk and will never be able to again, or whatnot, does not mean we pay for them to be in a nursing home; if they’re not actively getting better, it’s not “medically necessary”. Here’s the hint: if you could stay home with grandma, with no extra training (or very little) and she’d be fine (what’s called “adult supervision”-things like cooking meals, making sure the stove or the water gets turned off, the house gets cleaned), it isn’t “medically necessary”.

All of this is done for one and only one reason: to safeguard your money. Yes, yours. If you have insurance through my employer, you pay us to pay for your care under a set of rules. I enforce the rules. And it’s my job to see that they’re enforced equally and fairly. If you don’t get something, neither should anyone else insured like you, right? If the rules say “no kidney transplants” (no rules say this, but I need an easy example), wouldn’t you be angry if I told you no, but Myrna down in accounting got one? So I’m there to enforce the rules. Often the rules don’t say “No”, but they say “You have to try cheap generic drug X before you can try slightly more expensive drug Y, which you must try before you get fancy brand name Z”, or “You must have physical therapy before you have back surgery, because often, physical therapy makes you better and you don’t *need* surgery”, or “You must actually have gallstones, or some other thing wrong with your gallbladder, before you have your gallbladder out”.

Sometimes they actually *do* say “No”. So, no, you can’t have highly targeted (and extremely expensive) chemotherapy unless there’s proof it will work for what you have. Using kidney cancer chemo for colon cancer without proper study is an experiment, with a very limited number of subjects: just you. You can’t have an artificial heart-they’re all experimental, because they can’t be shown to do any good in the long term-even if the patient makes it to transplant (which is all the FDA allows, at the moment), they often do less well at transplant. We won’t let your doctor waste everyones money on a Hail Mary, God I Hope This Works one in a million shot-even if you want it. Because one in a million shots often cost many millions of dollars, and it’s not fair to all the other people who paid those millions that you get the Hail Mary pass which has either a very small, or an unknown, chance of working, and as a result they don’t get their gallbladder, their statin, or something else which *does* work, guaranteed.

Let me break this down for everyone: Every time an insurance company says “No”, it’s because someone like me (and it’s almost always a doctor-the rule in general is anyone can say yes, but only a doctor can say no) has looked hard at it, and decided that 1) there wasn’t any good reason to do it (hysterectomies fall into this on occasion, as well as gallbladder operations, spine operations and joint replacements. Trust me, I’ve seen some sad-ass excuses for doing these things. Once, it was “well, the pain is generally on the right side. Must be the gallbladder.” And then everyone is surprised when taking out the gallbladder doesn’t fix the problem), 2) it was experimental (artificial hearts, anyone? Hey, I dreamed up this cool new treatment for cancer; we tested it on a few people and they didn’t die for almost a week, and I patented it. How about you pay premium money for it?), 3) it was basically requested for the convenience of the person who is requesting it (you’re in Philadelphia and have a heart attack; you’d like an air ambulance ride back to Boston so you can get care at the MGH. Well, guess what? Philly has some adequate hospitals one of which you are currently in, and an air ambulance ride costs $30,000. What say you stay there, get the care you need, and buy a ticket on Southwest when you’re better? Saves us $30,000, and you’re just as well off as you would be here), or some variant on these themes. It’s not because I, or anyone else, doesn’t want you to get better. We wouldn’t have done health care all those years (I have 16 years of direct care experience, not counting the years since joining my current employer; the aggregate in my workgroup is probably about 160 person-years of actually giving care to patients. We’ve been around; we are, in fact, doctors and nurses). We really, really do want you to get better. Among other things, and only a little cynically-healthy people don’t use insurance dollars. But if you must use them, part of my job is to make sure they’re being used wisely. That you, and your co-members, are getting good value for their money. And when you tell me “Well, my doctor knows me better than you” I say “You’re right! And s/he’s in the best position to explain to me why I should pay for what s/he is asking on your behalf”. But if your doctor can’t make a case, likely there isn’t a case to make; it’s a waste of money, and they’re wasting money in order to either retain your business, drive up their bottom line, or because they’re not bright enough to see that they’re wrong.  (In fairness, on occasion there is a legitimate difference of opinion regarding what it means for something to be “experimental”; my experiment is someone else’s leading edge). Those guidelines I talked about? We, and the companies which make the others that we use, don’t make them up-we look at the science, we ask consultants in the fields what works and what does not-top people-Harvard, Stanford, Baylor, Penn, the folks at the bleeding edge. (Often those same people complain when we enforce the rules they’ve helped craft against them; don’t I know who they are? Well , often I do; or I don’t, but either way, I don’t care. Neither they or you are special snowflakes with different physiology or biochemistry than the rest of humanity). There are rules; I try to be fair in my application of the rules, as do my colleagues, and the reason there are doctors making these decisions and not accountants is that doctors are in a position to decide that the rules don’t cover this specific situation, and make exceptions which make sense. But they have to make sense; they can’t happen just because you are desperate, or determined, or politically connected, or loud. Because that isn’t fair.

And that, folks, is what utilization review actually is. An attempt, by frail but expert humans, to apply the rules equally-to be fair. Are we sometimes wrong? Sure. We can but do our best, and sometimes our best is ill-informed, either about you, or about the latest science. Sometimes we simply haven’t had our coffee. But we are trying to be fair, and at the same time, trying to safeguard *your money*. No matter how many dollars I save or spend on any given day through saying either no or yes to paying for something, I get paid the same; it’s not like I’m on commission. If I save a buck, it means a buck which we can spend doing something else for you or someone like you, not that I get a nicer office. So think about that before you complain about the damn insurance company telling you what to do. Maybe we’re right.