The Many Faces of UM: UM as a Path to Value-Based Care

"UM absolutely has its place," says Dr. Cathy Moffitt, Senior Vice President and Aetna Chief Medical Officer at CVS Health.

Part 1 of HealthLeaders’ series, The Many Faces of UM, posed the question: Is UM largely obstructive — little more than a payer profit-protection mechanism marked by excessive, over-automated denials — or is it vital for achieving the highest aims of value-based care? Part 2 explored the first part of that question.

Now, Part 3 explores how UM can be a vital part of the path to value-based care — one that helps achieve the now Quintuple Aim of healthcare to improve population health outcomes while controlling costs, closing health equity gaps, and ensuring that the patient and healthcare workforce experience are good ones.

As far back as 1991, CMS — then the Health Care Financing Administration — wrote the following of UM.

“The point is that the need for UM goes beyond the issue of controlling costs. UM is a primary approach that public and private payers can use to determine if patients are receiving appropriate care and if the money spent on health care is providing value. With this information, payers are in a better position to make informed decisions about health plan and delivery system changes that will lead to greater value.”

At least one payer believes it’s possible.

 “UM absolutely has its place”

“This is something I'm passionate about,” says Dr. Cathy Moffitt, speaking of UM.

The Senior Vice President and Aetna Chief Medical Officer at CVS Health explains: “I have been in the payer space now for over 20 years, and I spent a lot of those years as a medical director actually reviewing utilization cases on a daily basis. I believe that utilization management absolutely has its place in securing the right care at the right time, for the right reason.”

Not that cost isn’t a factor.

“Healthcare spend is at least 72.3% of the country's gross domestic product. I think we have a role there, but the way we do is to look very, very diligently at the clinical evidence,” Dr. Moffitt adds. “We all have a responsibility to be mindful of the enormous cost of care, especially low value or unnecessary care.”

A focus on clinical evidence is one of three examples Moffitt provides for Aetna’s application of UM.

UM grounded in evidence-based medicine

Moffitt is clear on Aetna’s payer role in UM

“We don't practice medicine, and we don't directly give medical advice. We do endeavor to help members receive appropriate care.”

“When a decision is truly aligned with the best medical evidence, we are able to render a determination that this is safe, effective for the member, and it won't be deleterious to them.”

She adds: “We have over 800 clinical policies that we rigorously maintain. We update at least annually with peer-reviewed journal articles and the standards of practice, both regionally and nationally.

The CMO is also clear on how payers and providers must work together for UM to be effective.

“Payer-provider collaboratives support care to patients that lowers cost, provides a better experience to the members and helps address healthcare based on race, gender, sexual orientation, gender identity — all of the equity buckets that we are so committed to in terms of improving the experience of care for our members.”

“As someone who's been in this industry for over 20 years, I believe with all my heart that the best way to line up all of those priorities (cost, quality, access, equity, workforce) is to have meaningful engagement with providers as true partners.”

UM grounded in provider differentiation

Differentiation is one of Aetna’s UM provider strategies and it links to the payer’s focus on evidence-based medicine.

“We are looking across our networks for providers who have sent us largely approvable cases because they are already ascribing to the same standards of medical necessity in their clinical decision making that we do,” says Moffitt.

The Aetna CMO adds: “We are looking for more opportunities to differentiate those providers and free them up on a case-by-case basis from the utilization management process.”

“That way — with the appropriate continued engagement between us and them, and the appropriate clinical monitoring — we feel like that is a very important part of improving the whole picture. Because again, our remit is to control cost, make sure our members receive appropriate, high-quality care, ensure equitable outcomes, and enhance the experience for members and  providers.”

UM grounded in real-time data

Dr. Moffitt notes that Aetna’s “provider differentiation” strategy relies on historical data that “helps us understand when services are submitted but rarely denied.”

But historical data is just the beginning. The use of real-time data to realize UM’s broader promise is key for health plans like Aetna.

“This is where payers can really lean in, because a lot of utilization management is historically post-review/post-service, which doesn't give you that sweet spot, that magic moment where you can get in there and get involved in real time when the care is being provided.”

She adds: “A lot of people would not receive real-time care coordination and the navigation services that we feel that we are able to provide.”

With this, Dr. Moffitt hints at the necessary companions for modern UM programs — featured in next week’s Bonus Brief and conclusion to HealthLeaders’ series The Many Faces of UM.