I recently finished my second month working in the field of utilization management (UM). The learning curve is steep! Thorough training and a supportive team have made for a smooth transition. Moving from direct patient care to the payor side has been eye opening. Here are 5 insights I wanted to share from my experience to date.
Providers may be unaware that peer to peer calls are scheduled.
When there is a concern about whether or not a patient continues to meet medical necessity for ongoing psychiatric admission, a name and date/times will be forwarded to me to reach out to the MD/NP/PA caring for the patient to have a discussion regarding their care. This information is provided from the utilization management contact at the hospital/facility. It is not uncommon that the provider does not know that a call was scheduled. This means that I have reached people on their day off, when they are driving, or (yikes) before they have risen for the day. This can make for an uncomfortable and unproductive interaction.
There are 60 lifetime reserve days for Medicare patients. Once they are used. That's it.
A person with original Medicare gets 90 days each benefit period they can use to cover inpatient hospitalizations. There are an additional 60 days that can be used only once. Why is this so pertinent to behavioral health?
Some with severe mental illness lack insight and are non-adherent with medications and treatment. Substance abuse tends to occur in cyclical patterns. This may lead to repeated admissions, often in the same benefit period. There are many barriers to identifying safe and appropriate housing and treatment programs for individuals with mental health and substance use disorders. What I have observed is that inpatient facilities will retain a stable patient in the hospital while they seek housing or a treatment program. A best case scenario is typically for a patient to leave the hospital and go directly to rehab, a nursing home, etc.
Yet, it is important to consider future needs of an individual and the fiscal implications of keeping stable patients on an inpatient unit for weeks (or months) at a time while an "ideal" placement is sought. It may be more prudent to consider a transitional housing situation and continuing a placement search outside of the hospital.
Many physicians/LIPs providing care on inpatient units do not know the criteria used to determine medical necessity for admission and continued stay.
As a physician who spent the majority of my career working for the federal government (in the outpatient setting), I will admit I was only superficially familiar with MCG criteria before I started my UM position. I had never heard of local coverage determination (LCD), which I now use daily. The business of medicine is so vital; exposure to this information should start in residency training. When my counterparts do not know the basis for case determinations it is as if we are speaking two different languages --- and it is not surprising that frustration and misunderstandings frequently occur.
I still use clinical skills daily.
Transitioning from direct patient care, I worried about losing my clinical knowledge base moving to a UM position. While I am sure I will eventually get rusty in the patient interaction arena, I use my clinical knowledge daily when performing chart reviews and determining medical necessity. Some times I will have a patient referred for review who has been in the hospital for an extended period, is not improving, and having no (or very few) medication adjustments. I may encounter a case in which an individual is having medication side effects or medical complications that have to be factored into determining criteria for a length of stay. I have read more about ECT and catatonia in the last two months (than I have in the prior 4-5 years)! It has been nice to have confirmation that my clinical knowledge base will be intact in my current role
There is variation in standard of care practices. Surprisingly so.
I have worked cases from throughout the country and it has been interesting to observe the varied standard of care practices throughout states and communities. One sobering take home is how under funded and resourced the mental health system is in the state in which I reside. I have seen more clearer how legal statues in my state are lacking when it comes to facilitating care for individuals who are imminent dangers to themselves/others (or gravely disabled) . During my time in clinical medicine, I sent only the most severe patients for admission. Typically hospitals were on diversion, a patient may not having insurance, or there was no access to what was needed (inpatient detox for example).
Some areas of the country are well resourced. The fact that I am accustomed to managing a condition in the outpatient setting (does not mean that is the best means of doing so). Likewise, I would not keep someone in the hospital for 3 day give melatonin for sleep. Decisions have to be prudent all the way around.
I remain positive about my decision to transition from direct patient care and am looking forward to continuing to grow professionally in my new role.
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