Utilization management in radiology: basic concepts and applications

Abstract

With the current constraints on health care resources and emphasis on value for money, resource utilization must be constantly revised and its value demonstrated. For this purpose, utilization management (UM) provides a series of methods to evaluate the appropriateness of health care resources. The ultimate goal of UM is to achieve the best patient outcomes using the most appropriate resources. The implementation of these procedures also targets variation in practice and promotes cost-effective clinical decision making. Inappropriate utilization is a major problem in health care today, particularly in capital-intensive fields such as imaging. High imaging utilization supposes losses to insurers and care-provider organizations and an overload for radiologists, while underutilization carries significant risks for patients, with the potential for a negative impact on outcomes. Imaging use must be assessed as frequently as new technologies arise. Given the fast pace at which this is happening, UM provides a crucial solution for continuous revision and assessment as an integrative process. The authors offer a practical guide for radiologists in UM, describing its role in today's health care finances. The key issue is to present UM as an approach for improvement that could bring benefits to all parties by adding efficiency to the health care delivery process. Utilization management represents an important opportunity for radiologists to be involved in the decision-making process, regulating the use of their services and providing fast feedback to other specialties that rely on imaging as a complement to their clinical practice.