Hi, everyone. This is Lucas Voss with Becker's Healthcare. Thanks so much for tuning in to the Becker's Healthcare podcast series. Very excited to talk about today utilization management that works, story strategies, and what's next. And I'm also very excited to be joined by Chad Kersting, business development director, eviCore by Evernorth, and doctor Eric Gracious, national physician executive also of eviCore by Evernorth.
And it's great to have you both on, and I wanna start with introductions, to get us started here. Doctor Gracious, why don't you kick us off? Thanks, Lucas, and I appreciate the warm welcome. As you said, I'm Eric Gracious. I'm currently national physician executive for medical benefit services
at Epicor by Eber North. I'm a pediatric hematologist oncologist by background, as well as a general pediatrician, and practiced for a number of years before jumping into the utilization management business about twelve years ago. And I've worn a number of different hats over time from patient care to research to teaching, and, again, most recently in utilization management. And, it's a complex issue, and I'm looking forward to digging into it with you today.
Yeah. Absolutely. Excited to have you on. Chad, we'll kick it over to you. Thanks. Chad Kersting. I've been with eviCore by Evernorth for, going on my tenth year now. My background is in consumer behavior, influencing consumer behavior, changing consumer behavior.
And, that is the division I started with at eviCore and have been able to expand, that role and and really, how can we bring more of that consumerism and education and things that eviCore was doing on the side, years ago to be more of a focus and and how can we help people? So beyond utilization management. So looking forward to having a conversation today. Yeah. Absolutely. It's exciting to bring both of your expertise together for this conversation. It's it's very it's great opportunity.
And I wanna start with doctor Gratias. Utilization management, we'll refer to as a as throughout the conversation just to make it a little bit shorter here, often gets boiled down to prior authorization. What do you see as the most misunderstood or underappreciated aspects of today? Well, Lucas, thanks for the question. You I mean, you you really nailed it with that
with that lead in. A lot of people view utilization management and prior authorization as the same thing versus interchangeable terms. And really, prior authorization is one tool that's used to manage utilization. So utilization management is really simply making sure that a patient gets all of the health care that they need and none of the health care that they don't. Mhmm. So that includes multiple multiple different types of utilization management.
The most common is addressing what we would call over utilization, which is when patients are receiving health care services that aren't going to benefit them in any way at all. And prior authorization has historically been used to address overutilization. And overutilization management has gotten the the biggest component of the attention, which is why the terms are interchangeable.
But what people don't recognize is that effective utilization management also addresses misutilization, meaning that a person needs health care services, but the the health care services that are most likely to help them are maybe slightly different than the ones that are being proposed. And so a great example would be someone who their physician has ordered a CT of their head to evaluate,
something like a headache. But when you look at evidence based medicine and apply it to that patient for the reasons that you're looking at their head and their age and their other symptoms and things, an MRI would be a better study. So utilization management will actually connect with that provider and talk through the evidence and often result in a change in plan to that alternate study, which is gonna be better for the patient.
And then the a bigger component, and, you know, it's where Chad and I are gonna spend a little bit more focused today is on underutilization and which is also part of utilization management. And this is something that actually quite a lot of people in health care are engaged in, and that's addressing services that people aren't using as much as they should. So a really common example there would be routine vaccination or cancer screen or something that we know can drive benefits.
But people, for a variety of reasons, don't use as often as is recommended. And so a lot of hospitals and physician groups are actually involved in this part of utilization management or the guys of names like gap and care closure or care coordination. And so when you think about utilization management more holistically, it really encompasses addressing all of those facets of inappropriate utilization.
And prior authorization is just one of many tools we have, which is a workflow processes, and it involves getting approval for to proceed with the services before leaping in, to the service delivery. Yeah. And you've touched on this a little bit, and I wanna come back to it. This is sort of a a a follow-up to this as well. So what do we need to do to shift this? What are the shifts that are needed to then improve this process to better serve clinicians and patients?
That's a great that's a great question. So there's a number of kind of core principles that that you'll hear about out there in the world. So one is just broadening understanding. And when a kid will understand what utilization is supposed to be and that it is intended to be a collaborative effort. And this should be something where all the involved parties are are shooting for the same goal, which is the optimal health for the patient that's under discussion.
I think we need more transparency around what the gaps in care are, what the utilization needs are for this person, and what are the sources of evidence, that are that are used and necessary to to help determine that. And you can only get there through through
better information sharing. So there's a lot of efforts around you hear the word interoperability out there, which is essentially just a technical term for being able to more easily share clinical information or other important information about a particular patient through electronic means and more in real time. So there's not this back and forth of phone calls and faxes and
and other things. And then, you know, the the most meaningful thing that we could do to really shift that focus would be to move the workflow further upstream so that you know, right now, a lot of utilization management processes come in after a physician and a patient have discussed a course of action and come to a decision on how they wanna move forward with sometimes without the the benefit of some of those evidence based guidelines being necessary at the point of care
when that decision is being made. So when you start your workflow after that that thoughtful process has occurred, you've got an entity who's already a little bit on the defensive because they feel like they're defending a decision they've already come to in good faith.
And if we could be further upstream and we were be a technical integration into the workflow, of that electronic health record, you know, and those decision aids around some of the evidence were there in EHR at the point of care, and we're enabling some of those discussions between the physician and the patient. The combination of that transparency and that technical integration of being further upstream.
If we could somehow, you know, accomplish those at scale overnight, the whole discussion around utilization management would change. You know, we've certainly seen that in pockets where we've had, you know, one off opportunities to connect at that level, with folks that does change the conversation. And all of a sudden, this process is viewed as a support rather than a barrier. Yeah. It's a more active a more proactive approach really moving from reactive to proactive, which I think is so key.
You've touched a little bit on underutilization as sort of one of the primary pieces, and you've mentioned an example there. And I wanted to come back to that. So this is, of course, talking about members not accessing the care they need. Can you walk us through an example where that was effectively addressed and changed and and what organizations should really take away from it? Well, sure. So I'll give you one where we we leveraged one of our own workflows. And and and again, Chad will go
into some of this as well. But, you know, we have one of our underutilization programs involves closing gaps in cancer screening, where we have, patients that we know are overdue for their breast cancer screening like mammography. And we have, we have the ability to monitor,
our overall systems. When we when we receive a prior authorization request, for example, or again, Louxter radiology is an example of radiology study, and that comes in as we're about to issue an approval for that study, the system will run a query and say, oh, this patient is on our list of people who are overdue for our mammography. And that outreach call will be transferred from our normal outreach unit to our preventive care team who will call that person
and say, hey. We've just wanna let you know that your your MRI has been approved, and I hope your hope your shoulder feels better and everything goes well with that. But, hey. While while I got you on the phone, it looks like you're overdue for your mammography. You know? And I know you're in your shoulder taken care of right now, but certainly while we got you here, is there anything we can do to kinda help you get that closed? And and, you know, and then the person can
say, well, you know, gosh. I have. I've just been so busy, and and we're able to leverage, the network of radiology facilities in their area. We can go ahead and get the study scheduled for them. Then we stay with them and follow-up to make sure that it was done and they got their results. If there was follow-up care, we help connect them to that.
And just by kind of leveraging that existing connection, we already had where the the person was already expecting to hear from us and then taking advantage of that moment where we've got them engaged on the phone just to try to see what else we can do to help help them, you know, navigate their care and taking the time to actually solve it for them in the first call.
That's an example that we we were helped to close a gap in care for that for that woman, and that wouldn't have existed if there wasn't a prior authorization process in place for her. So the change that really made a difference here, you've touched on it before too, was the shift to that more proactive approach. Correct? Correct. It was the it was the combination of being proactive.
It was just taking the time to stay on the call with her and take the extra time to, you know, check her, check where she lived and see who was available and talk to her about her calendar and get it all scheduled. But, also, I think piggybacking on a communication channel they were expecting to engage with, which is where we have more success than a historic approach of a more of a cold call. Because, you know, we we've all been, you know, bombarded by robocalls and spans and
other things. So peep you know, you know, a lot of people just don't pick up the phone and answer when they get a call from a random number they're not expecting. So I think it's the hook of being leveraging that communication that we we already have in place with them and then taking the extra time while we've got them and using that moment to help move their care forward. Yeah. Absolutely. Chad, this is where I wanna bring you in and and your expertise specifically around the consumer,
as well. We talked about the proactivity, and there is, you know, an increased focus on maintaining health through preventative and proactive care. We certainly know that as opposed to just treating. How is that shift playing out within and what's enabling it, and and what are you seeing in terms of scalability across US Health Care? What does it look like?
So, you know, I think that doctor Graces brings up, you know, points out one thing that we do really well or and sort of changed that that thought process of is just being yes or no, but being a little more collaborative. But but really, it's it's bringing that patient into the conversation and and understanding what's going on with that person, having that conversation with that person to identify the barrier.
And utilization management really allows us to do that at a much higher touch point or contact level than we would be able to do if we didn't have it and what most other vendors and health plans have the issues with, and that is the contact. You know, doctor Gracious touched on it, and that is if someone's expecting they go to the doctor, the doctor says you're gonna need to have an MRI or or a CT scan on your knee. They've told them they need an authorization. So now that person knows,
that that's the next step. So when their health plan shows up on the caller ID an hour later, they answer the phone. Or when we text, let them know we have an update about that authorization that drives that inbound phone call. So that interaction, interaction with the patients and and really treating them like a like a person, I think is what what's what's a little different than what you when you think about
in the past. And and having that under, that it's that conversation to understand what's going on with them allows us to, uncover what that barrier might be, how how they've been affected, whether it's they can't take time off work to get certain things done, to go to their wellness visit or get their mammogram, or they're waiting two months to see their PCP because, primary care physicians are in a shortage and
they didn't know they had virtual benefits. So just overcoming that health care illiteracy. And where I see this playing out in health care is especially as we get more virtual offerings, as we make it easier to interact with patients and customers and members via either some of those apps that are out there where we're able to have those two way conversations or or two way text conversations that
that we utilize. But I think you'll see it utilized more and more as, utilizing that that capability more and more of actually interacting with the person to understand what's going on in their lives more than just case management, I think is what's different and where where we're headed. Yeah. And I think it speaks to the fact that, again, we're looking for personalized experiences,
right, in our day to day lives. We're looking for that support that's customized to us, more of that consumer experience. I'm really curious to see you've touched on this a little bit. How do you see this trend evolve over the next five year? What's going to happen here, especially when you're looking at at I mean, I think one of the things that we've already started to do, and, again, doctor Gracious touched on it, earlier, and that is, that that person comes in or enters a health care journey.
Knowing what else that person is due for or what else is going on in that person's life as EMRs get more and more connected or as even, we're able to collect more of the results from the scams to know, what were the results. And then being able to pair that up with either other authorizations that we've done or if it's Evernorth and ESI, what drugs are they on? And we get a cardiovascular request come in, and we can see they're taking this drug, just this drug, this drug,
and this drug. They've had this pre auth pre auth and pre auth. Now they're asking for this. Where is this person headed? What does this person look like five years ago? What do they look like now? And being able to predict that and address certain things ahead of time, or are they working with the right providers? Are they you know, what vendors are out there, either the services that we offer?
By looking at the data and seeing what's going on with that patient, are they working with the the the right groups in the to to effectively treat their condition? And being able to provide clinical decision support to their providers and and looking at things holistically. Because you sort of pointed out earlier that we are in the business historically of treating illness. People enter the health care system when they're already sick.
But if we have the data on that person, we can pretty accurately predict what's coming next for them. And being able to do that at scale across our book of business, that is something that isn't very far off. Yeah. Absolutely. Chad and doctor Gracious, I wanna thank you both for your insights and time today. This is a fantastic conversation. It sounds like proactivity is the name of the game, which is very, very important.
We also want to thank our podcast sponsor, eviCore by Evanorth, and you could tune in to more podcasts from Becker's Health Care by visiting our podcast page at beckershospitalreview.com.