EK HEALTH

by Richard Thompson, MD
EK Health Services' Chief Medical Officer

Utilization Review came to California at the end of 2004 and radically changed the treatment model for injured workers as well as for treating physicians. The utilization process has certainly evolved during this time and physicians, patients, insurers and lawyers have learned they must deal with the new realities, including evidenced based medicine, medical necessity, medical reasonableness and appropriate care. This evolution is now leading us into the area of uniting utilization review and bill review.

At EK Health all of this translates into new teaching models for our UR physician reviewers and our EK staff as well as the development of newer and sophisticated technology.  It requires that we work closely with our clients as we face an almost constant barrage of new challenges from treating physicians, injured workers, vendors, and lawyers. We must focus on issues that are critical to our ongoing success, such as quality, service, personnel, efficiency, timeliness, clarity, objectivity, technology, and pricing. I am frequently amazed at the number of issues that can go wrong on a single review of a simple treatment request! Hopefully injured workers appreciate the benefit from continuous review and monitoring of their care.

With all of the changes, our organization has gone through since 2004, and in anticipation of even more changes ahead, it is an excellent time to address a few frequently asked questions “What is our philosophy of utilization review at EK Health? What’s important for our organization?”  In their simplest form, these questions can be summed up in two words: Quality and Appropriateness. Quality is a combination of professionalism, timeliness, and objectivity that influences our exposure to our clients and the treating physician. Appropriateness assures that the right patient receives the right treatment at the right time.

Our measurements of quality have moved from primitive to sophisticated. More and more clients are demanding data. What are the outcomes of denials? How many denials are overturned? How many approvals can be handled by non-physicians? Accessing our outcomes data will require working more closely than ever with our clients and developing the technology to retrieve such data. In order for EK Health to develop the finest utilization review organization (URO) we will require regular and measurable feedback about our program. We now recognize that the process is more important than the determination. Disentangling the process from the UR determination allows the URO and the client to observe the process rather than obsess over the content. With this experience, and our comprehensive proprietary software (Ahshay!), we deliver to our clients a mechanism for measuring the success of evidence-based medicine.

As we move forward in this hectic world of utilization review, we must do more than connect the dots. We must build rapport between EK Health and our clients as well as between EK Health and treating physicians. Granted the relationship between the URO and the client is more defined and more contractual, but the relationship between the treating physician and the reviewing physician often becomes, over time, professional and respectful. This leads to thoughtful, appropriate care for the injured worker. 

At EK Health, we find our physician reviewers often alternate between the dual modes of experience and treatment guidelines while our clients often alternate between the dual modes of medical costs and program costs. But all parties must recognize the legal and administrative burden of our shared UR program and hopefully all parties appreciate that while there is more than one reasonable way to proceed in complex processes and programs, sharing our goals, experiences, and expectations is the path to success.