Physician-Controlled Utilization Management

TO THE EDITOR:

In their article on managed care and capitation, Kerr and colleagues [1] overlook the fact that physicians' resource utilization meetings also gather clinicians together in a collegial atmosphere to discuss their patients, thus functioning as a multidisciplinary brain trust. This is neither gatekeeping nor utilization management. We have renamed this group our “Care and Resources Committee,” a term that more accurately reflects the group's purpose and function.

Implicit in most criticisms of utilization management is the shaky assumption that doing a requested procedure is, by default, the gold standard. This is the “might as well” mentality, which ignores the possibility and consequences of complications, including the “cascade syndrome” of tests and procedures that may be done as a result of minor positive findings.

In his editorial, Dr. Goldfarb [2] points out this problem: “Conversely, little evidence shows that the provision of more care than managed care techniques have deemed necessary leads to better clinical outcomes or even more satisfied patients.” Unfortunately, the media prefer to mindlessly bash managed care rather than objectively consider the burdens of unnecessary surgery, overuse of laboratory tests, futile intensive terminal care, and inappropriate care in general. All of these are more prevalent in a traditional fee-for-service environment.

Kerr and colleagues express concern that “decisions made without reliance on written guidelines may result in different approval criteria being used for patients with similar conditions.” Which guidelines? Nearly 2000 sets of published guidelines exist, and the number is increasing. The guidelines differ among themselves; few have received the nearly universal acceptance enjoyed by pediatric immunization schedules. What is the true value of consistently following one guideline when guidelines differ?

One cannot compare “similar conditions” without considering that technologic innovations and their implementation are constantly changing. When does a new treatment cease to be experimental or investigational? How many procedures qualify a practitioner to perform a new form of surgery? No nationally accepted standards yet exist in this crucial area. Thus, when seemingly different decisions are made for two patients, one must ask, “What was the exact status of the procedure in question at those two times?” Consistency has its virtues—it is a mainstay of the scientific method—but there will always be many subtle considerations that are unique to each patient and each authorization request.

Patient care committees are struggling with these issues. Such committees are the crucibles in which evidence-based medicine can be most pragmatically tested. I submit that the question the committees are asking themselves most often is, “What is best for this patient at this time?” and not “How can we avoid spending this money?”

• Copyright ©2004 by the American College of Physicians