The strategic imperative
It is estimated that up to one-third of all U.S. health spending is unwarranted, amounting to hundreds of billions of dollars every year. Ensuring appropriate use of expensive surgical procedures is a strategic imperative for healthcare providers and payers who want to improve clinical outcomes while reducing costs.
Payers have traditionally managed the use of costly procedures by requiring prior authorization. Increasingly, providers in risk-sharing contracts have additional incentive to reduce costs and be vigilant about appropriate use. Clinically trained personnel are involved on all sides to prove or deny medical necessity. The resulting administrative burden, cost of labor, and delays in treatment are a drag on payers, providers and patients.
Slash costs and time from medical necessity reviews
QPID Health’s utilization management solution addresses these issues by automating the data collection and analysis required to speed medical necessity reviews and determine the appropriateness of interventions.
The software applies sophisticated guidelines-based decision criteria to patient medical profiles to produce an optimal procedure recommendation.
- Spares patients the risk of inappropriate care and drives better outcomes
- Lowers costs by eliminating unnecessary procedures
- Reduces the administrative costs of the prior authorization process by 50%
The solution was first implemented at Massachusetts General Hospital as part of Partners HealthCare participation in the Pioneer ACO, and results are impressive. For example, MGH has documented dramatically lower rates of inappropriate use of diagnostic catheterization for suspected coronary artery disease than national averages: 1% compared to over 28%.
The program has now been rolled out across the entire Partners Healthcare network for 20 high-cost and high-volume cardiac/vascular, orthopedic, GI/GU, and surgical oncology procedures. Clinicians and their staff are excited about the software, which makes them feel confident that their decisions are evidence-based, and helps them communicate personalized risks and benefits to patients.
Further, payers including Blue Cross Blue Shield of Massachusetts have agreed to forego prior authorization where the system is used, saving time and resources.