It’s the latest industry recommendation: that health plans move routine Utilization Management (UM) in-house and leave complex, specialty care to the experts. As both a nurse and a clinical operations leader, I couldn’t agree more.
One in 10 babies is born preterm, and that number hasn’t changed meaningfully in years. A crisis that stays a crisis is unacceptable, but moving the needle isn’t easy. Neonatal intensive care unit (NICU) admissions are clinically complex. They require a specialized skill set to protect babies and prevent the variations in care that increase length of stay and cause preventable readmissions.
Specialty NICU UM can make an impact, improve outcomes, and lower overall cost of care through:
The Healthcare Payments Industry Faces a Perception Challenge
Healthcare payments are no longer about transactions. It’s about controlling the revenue cycle. And increasingly, that control is not sitting with ISOs.
- deep clinical expertise
- seamless provider collaboration
- advanced technology that captures data and contributes to managing the care continuum
Done well, NICU UM is so much more than an approval process. It is a clinical credibility engine that — when integrated with Case Management (CM) — drives every NICU admission toward the most appropriate, impactful care.
The real story of NICU care
There is a time and a place for specialty UM, and it’s the NICU.
Inside an Automated Healthcare Practice: Redesigning Care Around People, Not Paperwork
By reducing administrative burden and redesigning workflows around human needs, it creates space for what matters most: connection between clinicians and patients.
Preemies and medically complex babies need more than good hospital care. They need a coordinated plan that follows them home. Without it, these babies face the very real risk of ending up back in the hospital. That’s no way to start a life. An effective NICU UM program can be there for every moment that a critically ill baby spends in intensive care.
In the NICU, it is critical that clinicians feel empowered to make timely, evidence-based decisions for their patients. A specialty UM team acts as a trusted advisor, extending the care team, lending expert support, and leveraging institutional knowledge so that each NICU admission receives an even greater level of individualized attention.
This peer-to-peer model delivers deep clinical insight to every NICU case. Specialty UM experts can collaborate directly with hospital care teams and families from admission through discharge and beyond, guiding babies through critical milestones and supporting discharge planning. This ensures that every decision is informed, timely, and focused on the best interests of the baby and family.
Cost containment and improved outcomes
Preterm births and NICU admissions are among the highest cost drivers for health plans. But that is only part of the story when it comes to the NICU. A well-designed and executed specialty program can have a significant impact on cost by delivering the right care at the right time.
For Medicaid and commercial populations alike, the best NICU UM partners prove that they can:
- reduce NICU length of stay
- reduce readmissions significantly
- generate consistent savings
This should be true for every baby admitted to the NICU — a place where outcomes are known to vary based on race, location, and access to innovative care.
An effective UM program can help level the playing field through clinical expertise that drives results. A NICU UM team led by specialty nurses and medical directors serves as a right hand to health plans, hospital care teams, and families — from admission through discharge planning and beyond.
UM-CM integration supports holistic care
One of the biggest misconceptions about UM is that it creates a dysfunctional system marked by delays in care and denials. But these are symptoms of poorly integrated, generic UM models — not specialized, collaborative, and multidisciplinary approaches. Such approaches are built on clinical partnership, evidence-based guidelines, and real-time engagement with providers.
A specialty program that integrates UM and Case Management (CM) is essential. It provides multiple layers of support to monitor babies, early and closely; promotes collaboration between NICU teams and high-risk care managers; and engagement of families.
UM-CM integration supports a whole-person approach by addressing the medical needs of babies, the emotional needs of every caregiver, and the social determinants of health of the entire family. Integration helps meet patients where they are. It reflects a deep understanding of where things are working in the system and where they aren’t, and guides care in the right direction.
Tech-enabled UM captures every NICU moment
Integrated UM-CM must be supported by advanced technology. The best UM platforms provide a complete digital footprint of each member’s journey and consolidate it into a single case record.
Effective UM platforms promote adherence to evidence-based clinical guidelines to strengthen decision making. Finally, there is transparency, which promotes trust and ultimately, the safety and well-being of babies and families.
This functionality and approach are necessary to support health plan clinical priorities; reduce costs and readmissions; and improve member outcomes, family engagement, care navigation, and provider satisfaction.
The NICU isn’t the place for generalists
NICU readmissions, excessive length of stay, and inconsistent outcomes have recurred for far too long. At a time when health plans are feeling enormous pressure to improve outcomes and contain costs, specialized UM is essential. No one can solve this alone. Decreasing preterm births requires a nuanced response that spans the NICU continuum of care.
And so, the industry experts are right: utilization management isn’t an either/or decision. It’s both/and: in-house solutions for routine UM and a strategic partner for the high-stakes, specialty UM needed in the NICU. It’s the right call — for providers, for health plans, and most importantly, for every mom and baby.
Photo: Kwangmoozaa, Getty Images
In her role as Senior Vice President of Clinical Operations, Madeline Szabo has responsibility for the utilization management and case management programs at ProgenyHealth. Her primary goal is to drive performance and demonstrate the quality and value these programs bring to customers.
With over 25 years’ experience in the managed care arena, Madeline has developed a keen understanding of key aspects of the healthcare industry. Prior to joining ProgenyHealth, she served as Regional Director and Associate Vice President with both Molina Healthcare and Aetna. In these roles, Madeline developed and implemented CM and UM programs to support lines of business that included commercial, Medicare, and Medicaid membership. Her focus on data-driven decision making helped her teams succeed by improving the overall quality they delivered to plan members.
This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.