Happy Thanksgiving from UR Nation

| | Utilization Review

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Thanksgiving Graphic from RS
When we think about Thanksgiving, many of us start listing the things we are thankful for – health, family, prosperity, etc. However, this year as I have been thinking about perspective. That may seem weird, but each day as we go through our day, everything really is about perspective. People say, “Wow, they are rich!” But how is rich measured? Is it by wealth, by friends, by being loved?

In the world of insurance, we tend to focus on getting things done or moving onto the next task, and I would argue that we don’t always stop to think about the perspective of those that are impacted by the injury. In my world (utilization review), perspective comes from the clinical documentation by the treating physician. This makes the the need for quality medical documentation critical.

If the clinical documentation is lacking and doesn’t depict the entire picture of the person’s injury, progress, limitations, and success or failure of prior treatments, it’s far more difficult to move the treatment along. The following are common perspectives from each of the parties involved in a work related injury:

  • Injured worker – They don’t care about me or helping me get well.
  • Employer – Please recover quickly and come back to work.
  • Treating physician – The insurance companies need to allow me to treat my patients based on my experience and not box my treatments into medical guidelines.
  • Adjuster – We utilized treatment guidelines because they are based on evidence within medicine and should be the end all, be all, with no  exceptions.
  • Insurance carrier – We just want the injured employee to get well and return to work.

Essentially, the clinical documentation must paint the picture to support the treatment request. If it doesn’t, then the treating physician cannot do their job of assisting the patient to recover quickly, return to work, and keep medical costs under control by treating according to evidence based guidelines.

As we all know, the high costs of medical care seems to increase exponentially each year and is driven based on the cost of treatments, including prescription drugs (contributing to an opioid crisis), durable medical equipment, hospital costs, surgical implants/graphs, etc. The frustration rises along with the costs.

Our underlying desire (for all parties) is to ensure that we are treating the patient’s injury appropriately (based on evidence based medicine) and returning them to the normal aspects of their life post injury. Is this an easy task when it comes to all of the above perspectives? No, it’s not. But if we think of the fact that we are basing our decisions for the betterment of all, can’t we rise up and be effective?

As we gather for Thanksgiving, my request for you is to take a different perspective on Thanksgiving and going forward: What is right? What is based on fact/evidence? What is true necessity?

Happy Thanksgiving – Please enjoy your time with friends and family, and enjoy this holiday as a period of reflection and perspective.

Gobble, Gobble

Karen Atkins

Karen Atkins, Chief Operating Officer with UniMed Direct, is leading the conversation, and the industry, on how to make the utilization review process more efficient for all stakeholders: physicians, insurance companies and, most importantly, patients.