Consumerism and the Independent Review Process

At the recent URAC Quality Summit in San Diego, we attended several sessions that focused on consumer directed health plans and the advent of consumerism in healthcare was the dominant topic at the conference. As many of you know, URAC is an accreditation body that governs IROs as well as utilization review, medical management, health plans, and other types of organizations in the healthcare sector.

The topic of consumerism is a hot one right now. It really relates back to the whole issue of how consumers are being driven to take a higher degree of responsibility and become more involved in directing their own healthcare decision-making. Why is this? With the advent of high double-digit increases in health care premiums, cost shifting has forced consumers to become more involved in figuring out how it is that they're going to spend their healthcare dollars. Certainly, the advent of health savings accounts and other types of tax advantage plans has also had a major impact on this.

Many people ask us how independent review plays into the consumer driven health plan momentum that is gaining in the United States right now. The fact is that IROs, when providing independent medical reviews and pre-authorizations, are not dealing directly with consumers (or at least very seldomly). However, IROs are the behind the scenes mechanism helping to insure that patients get what they are supposed to get consistently according to plan language, standard of care, and necessity.

Consumerism does not effect the independent review process directly, other than the fact that as consumers become more involved in determining how and where they're going to get their healthcare treatment, there is certainly going to be more conflicts and questions that come up with regard to how those dollars get allocated in the system. This is where an IRO plays a pivotal behind the scenes role in this process. Consumers won’t come to IROs in order to get a claims pre-authorized or adjudicated, but individuals will indeed benefit from the IRO process as it relates to ensuring that patients get what they're supposed to and that subscribers receive the healthcare that they deserve according to the plan language that they subscribe to.

As consumer directed health plans continue to increase, and the independent review process becomes a bigger part of the mainstream of best practices for allocating healthcare resources, we expect the two to converge more and more even if IROs don't deal directly with the public.