Utilization Review Groups (URG), pronounced "ugh" by those in the health care profession, are much like HMO's; no longer necessary. For those unfamiliar with URG's, they were designed to manage care and were in early concept something that appeared to be a cost effective solution for employers. A company is approached by a URG to handle their workers comp claims. The URG contracts at a set rate to handle the claim from start to finish in regards to finding providers to see the injured employee and then handle the payment of the services provided. In theory this would work well in regards to the employer not having to find health care providers for their clients and then also not having to worry about follow up and care for their employee until they, the employees, were ready to come back to work.
Sounds good in theory. Unfortunately the only article that I could find about URG's was published in the New England Medical Journal (NEMJ) in 1995. A lot has happened in twelve years. URG's were too new at the time to have any real world data to assess how well they actually worked.
Even with the strong argument that utilization is driving health care costs rather than prices alone, do we need still need URG's? My answer is "NO".
Let me explain by giving an example from the description above in regards to the physical therapy setting. A company that classifies themselves as a URG contacts a local employer. Say they convince the employer to contract with them on an as needed basis for any workers comp claims. They reach an agreement on the price at $1000 a claim. What the URG will then do is look to find the lowest bidder from the local physical therapy providers to farm this claim out to. Why? Because the lowest bidder takes less of the $1000 and leaves more in the URG coffers. All the while the URG gets paid for what? Doing the leg work of establishing relationships with themselves and with lowest bidding physical therapy providers and with employers.
The folks at the URG make a few phone calls, send some E-mails, and then close the case out when the health care provider feels the client is appropriate to return back to work. Meanwhile it adds more paperwork, time to take phone calls, and reduces amount reimbursed for services to the physical therapy provider. It also adds administrative costs to the work comp claim because the URG has now inflated the actual cost of care. What is even worse is that the employer is now trusting that the care of their employees is being performed by highly trained qualified therapists. While it may be the case in some instances, most of the time the lowest bidder is not the best provider. If quality costs, why would the therapy group provide quality care for less money then it costs to perform?
A better, more functional scenario would be this. Employers establish relationships with local health care providers and physical therapists especially. Once the relationship is built, the communication lines stay open. All employees that are hurt get sent to the practice where a relationship is established. Necessary care is provided and the employee returns to work. No middleman, URG, asking for duplicate notes, taking up treatment time by calling, and no excess administrative costs. Also relationships are established with the best providers in town, the employer knows their employees are being taken care of, and they can manage their own costs by establishing reasonable rates for services provided without the hassle of talking through someone else.
So if URG's are not needed why are there so many in existence? I guess bad habits are just hard to break and it is easier to pass the responsibility to someone else.
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