8 December 2022By Maryanne Bourque,MS, BSN, ACM-RN, CRCR, Director, Utilization Management, Nurse Case Management, and Complex Scheduling, NemoursUtilization Review and Pediatrics: The Shift to Value-Based CareIN MY OPINIONPediatric free-standing health systems are uniquely different from adult hospitals not only in direct patient care delivery but in a variety of ways bearing on the business end of providing health care. As the landscape of reimbursement has consistently changed over the years, so too have the ways in which we view utilization review and management. Many of the underlying standards and principles of efficient utilization review for hospitals are underpinned by the Centers for Medicare and Medicaid Services (CMS). While there are certainly some children insured by Medicare and some insurers who adhere strictly to Medicare practices, there are profound differences. Managed Care Organizations (MCOs) are most often contracted to provide administrative support as well as to assist those enrolled in meeting necessary health maintenance standards, disease management, and overall coordination of care. Government funding of children's healthcare is dominated by state Medicaid plans. The Utilization Management team on the payer side seeks to manage costs, while the Utilization Review team on the hospital side is focused on ensuring full reimbursement at the correct level of care. As pediatric hospitals are some of the last remaining recipients of fee-for-service (FFS) contracts, the focus of interactions between the two sides of this equation has been around medical necessity, determinations of approved days, countering denials with appeals, and working to ensure all clinical information is transmitted successfully between the two sides.As the environment of health care reimbursement has already shifted for adult hospitals, pediatric health systems are moving more fully into value-based care, which will significantly impact the way in which Utilization Management is conducted. Payment models are moving through upside risk, shared savings, and full capitation. Along with those changes comes the need to look at care differently­to shift from acute episodic care and to focus more intently on illness prevention and health maintenance. In pediatrics, this is starkly different than adult medicine. Children's health is more often negatively affected by congenital illnesses, environmental factors beyond the patient's control, and accidents/trauma. The movement Maryanne Bourque
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