It looks as if utilization management (UM) will be sticking around for the foreseeable future, but that's not necessarily because it's working so well everywhere. In fact, it's the combination of prevalence and variability that prompted APTA to launch a new toolkit to help physical therapists (PTs) and physical therapist assistants (PTAs) understand—and be successful in—the UM environment.
APTA's UM Toolkit offers members a range of information on UMs that includes everything from the history of the concept to strategies for working with UM vendors and tips for reducing authorization denials. The toolkit's resources can be used by individual PTs and PTAs as well as APTA chapters, and are offered through both a collection of webpages.
Although the concept of UM has been around since the 1950s, the real growth in use came after the adoption of the Affordable Care Act in 2010. With the ACA's expanded coverage, inclusion of "essential health benefits," and emphasis on improved patient experience and reduced costs, insurers felt pressure to more tightly control the kinds and duration of treatments being used by clinicians. The physical therapy profession's experience of this shift was intensified by the fact that the effectiveness of physical therapy is increasingly better understood by a public that now has greater access to PTs—an evolution that has made PTs a target for "cost containment" efforts, according to the toolkit.
Making things even more difficult is the fact that UM—often conducted by third-party vendors on behalf of insurers—has developed in sometimes-haphazard ways, putting much of the onus for advocating for consistent, effective patient care on the clinicians themselves. That's why APTA's UM toolkit exists.
"There are inherent conflicts and difficulties when balancing access, quality, and cost," APTA says in the UM overview section of the toolkit. "The ultimate goal is a UM program that facilitates effective use of limited resources, improves appropriateness of care, and imposes only reasonable burdens on patients and providers."
APTA continues to engage with UM vendors and insurance companies to develop systems that are more responsive to PTs and their patients. The toolkit and other UM information is found on the APTA’s Third-Party Administrators (TPA): Utilization Management & Utilization Review webpage.