5 Key Steps for Transitioning to Upstream Utilization Management (UM)

Implementing Upstream Utilization Management

In last week’s newsletter, we provided an overview of Upstream Utilization Management (UM) and its main difference from downstream UM.  Shifting to upstream UM requires a fundamental rethinking of how health plans operate. Here are key steps to making the transition:

1. Invest in Preventive and Early Intervention Programs

Health plans should allocate resources to programs that address common drivers of high costs. This might include wellness initiatives, chronic disease management programs, and digital health tools tailored to member needs. In particular, plans should identify “modifiable” conditions where such investment can yield savings through health improvement initiatives.  Musculoskeletal (MSK) conditions are among the most well-known modifiable ones in that early engagement, treatment, and education clearly reduces the 30% unnecessary surgery rate (which, in turn, drives immediate and impactful cost savings).

2. Enhance Member Engagement

Upstream UM relies on active member participation. Health plans should prioritize strategies that make it easy and appealing for members to engage with their health. Personalized outreach, user-friendly digital platforms, and incentives for healthy behaviors can all drive engagement.  Often, health plans will partner with other companies in these upstream efforts; the plans must prioritize assisting in member enrollment.  This includes adoption of modern email marketing techniques and a willingness to provide support for the Upstream UM company to deliver these campaigns if not being done by the health plan. While member abrasion is a commonly cited concern associated with email outreach, the benefits far outweigh the downsides provided the outreach campaign proceeds in a mutually agreeable fashion.

3. Collaborate with Providers

Providers play a critical role in upstream UM. Health plans should work closely with clinicians to implement evidence-based care pathways, share data insights, and align incentives. For example, a plan might develop a shared savings program that rewards providers for reducing unnecessary imaging studies in MSK care. Otherwise, health plans can provide data insights to their provider partners detailing rates of surgical treatments, with benchmarks to peers. Health plans can also implement centers of excellence (COE) or preferred provider networks that reward providers delivering high-value care.

4. Leverage Technology

Technology is the backbone of upstream UM. Health plans should invest in advanced analytics, telehealth capabilities, and remote monitoring tools to enable proactive care. Additionally, integrating these tools with existing systems can ensure a seamless experience for both members and providers.  Sometimes, it is as easy as developing “groupers” of ICD or CPT codes that facilitate early identification of at-risk members. Plans can then use these groupers to measure impact of the upstream program on utilization and cost trends.

5. Measure and Refine

To succeed, upstream UM must be data-driven and outcomes-focused. Health plans should establish metrics to evaluate the impact of their initiatives, such as reductions in hospitalizations, improved patient-reported outcomes, and cost savings. Regularly reviewing and refining programs based on data insights ensures continuous improvement. Ideally, the health plan can establish a reporting framework that can apply to numerous high-cost clinical conditions and use diagnosis or procedure code groupers to appropriately include members with those conditions.

The Business Case for Upstream Utilization Management

The benefits of upstream UM extend beyond improved outcomes and member satisfaction. There is a compelling business case for health plans to make this shift:

• Cost Savings: By addressing the root causes of high-cost episodes, upstream UM reduces overall spending on care.
• Member Retention: Proactive, personalized care fosters loyalty and helps plans retain members in a competitive market.  Most Upstream UM companies boast member satisfaction scores that far exceed those of the health plan and even the in-network providers.
• Competitive Advantage: Health plans that lead in innovation and value-based care are better positioned to win employer contracts and attract new members.  Plans can negotiate for data-sharing with their Upstream UM partners so that the data can be used for the plan’s business development initiatives.
• Regulatory Compliance: Meeting quality metrics and value-based care requirements positions plans for success in Medicare Advantage and other regulated markets.  For example, Upstream UM partners can incorporate questionnaires and processes that assist health plans in these quality initiatives.  Examples include screening questionnaires for fall risk, tobacco, opioid use, and social determinants of health.

Conclusion

The healthcare industry is evolving, and health plans must evolve with it. Downstream utilization management, while necessary in some cases, is no longer sufficient to address the complex challenges of rising costs and fragmented care. By shifting to upstream utilization management, health plans can proactively tackle the root causes of inefficiency, improve member outcomes, and align with the broader shift toward value-based care.

The time is now to embrace this paradigm shift. Health plans that act decisively will not only reduce costs but also enhance their reputation as leaders in innovation and quality care. In doing so, they will position themselves to thrive in a rapidly changing healthcare landscape.

How We Can Help

Protera Health is the country’s leading Upstream Utilization Management company for musculoskeletal conditions. We help health plans lower costs while improving member health outcomes and satisfaction ratings.

If your health plan is ready to shift utilization management upstream, please schedule a demo with our team or sign up for our mailing list to receive exclusive content and event invitations.

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