Game Changers - Utilization

Leading practices across the country are taking a fresh look at Utilization. Why? Because Utilization is a key indicator of care planning and management, service value and outcomes, resource consumption, professional contribution, and financial performance.  Utilization tells an important story for those who are willing to hear it and are committed to excellence.

As we have discussed previously in this Game Changer Series, the twenty-first century healthcare environment is defined by the rapidly rising consumption of health services, increasing consumer expectations, exploding health care costs, and eroding provider reimbursement. These are not passing trends but rather the new normal.

Utilization metrics incorporate three core performance parameters that are relevant to care services, strategic planning, and financial management  – Visits/Case, Units/Visit, and Expense/Unit.

Utilization is all about goals, outcomes, right-sizing, and efficacy. Let’s consider each of these briefly…

Goals establish priorities, define expectations, and set direction. They are defined in care plans, implemented with scheduling, evaluated throughout the service cycle, reported in documentation, validated to justify reimbursement, cited for marketing purposes, and rewarded by compensation. Goals drive utilization. Utilization is dependent upon one's intervention focus – education, home instruction, pain relief, isolated segmental restoration, holistic functional rehabilitation, re-injury prevention, or performance optimization.

Goals involve both qualitative priorities (improved balance) and quantitative outcomes (Olympic gold medal on the balance beam).  Outcomes consider how high one sets the bar. Outcome expectations and their achievement often become self-fulfilling prophesies. What would patients want if they understood the difference between what was permitted, probable, and possible? What expectations are your utilization standards creating? What innovation are your standards driving?

Utilization decisions are influenced by who has knowledge,  power  and control over the intervention priorities and outcomes that are/can be established – the payor, provider, or patient.

Utilization constraints can be artificially introduced by payor benefits as in examples such as: 6 visits/case, 2 units/visit, or $75/visit. Such constaints are prone to protect payor profitability at the expense of patient needs.

Utilization can also be constrained by providers using one-size-fits-all planning and scheduling. When utilization is routinely defined as, “one-on-one for 60-minutes, three times a week for 4 weeks”, the primary constraint is that of provider habit where preference trumps possibility. One size does not fit all.


Utilization constraints such as a client’s community, family responsibilities, travel distance, transportation, work schedule, financial resources, insurance or lack thereof, benefit plan, and even the weather also affect utilization.

With all those utilization variables there are a lot of opportunities for a perceptive and innovative manager!


As Goldilocks discovered, in The Three Bears' world of “too big or too small”, “too hard or too soft”, “too hot or too cold”, there is tremendous value in “just right”. Right-sizing recognizes that utilization is influenced by constraints within an infinite spectrum of possibilities. Utilization must be actively and creatively managed.


Efficacy involves effectiveness and optimization – doing all and only that which will produce the best benefits in the shortest time, for the least resources. Often efficacy is assumed, with interventions being based more on matters of training, tradition, protocol, economics, and egos than on scientific evidence. Efficacy always impacts utilization either favorably or unfavorably. There is room for improvement. It is interesting that  nearly every professional claims/believes that they provide superior efficacy – just ask them! However, statistically we know with certainty that 75% of professionals do not. Utilization is greatly impacted by, as Will Rogers said, “What we think we know that just ain’t so.”

So what story is utilization telling us?

1.       1. Utilization increases when outcome priorities shift from pain relief to functional restoration.

2.       2. Utilization decreases when outcome priorities shift from functional restoration to payor profit.

3.       3. Utilization is optimized when priorities shift from medical diagnosis to functional impairment.

4.       4. Utilization is optimized when focus shifts from symptom relief to biomechanical cause.

5.       5. One-size-fits-all utilization dosage won’t work, doesn't work, and never did.

6.       6. Industry leaders will be those who understand the complexity of Utilization and get it right.

7.       7.  Industry laggards will be those who won’t let go.

Industry leaders understand that utilization management, like investment management, is optimized in the context of a portfolio where diversification, risk mitigation, short and long term goals, value, performance, and return on investment considerations are all interlinked. The simplistic management of utilization fails to deliver value! They recognize the complexities and opportunities of utilization and strategically optimize utilization for the benefit of those they serve.

The lesson of utilization is simply, “play smart or go home”.

All The Best!

Bob

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