In the late 1980s, changes were made to this method of monitoring care and utilization management (UM) was introduced. UM was the evaluation of the appropriateness, medical need, and efficiency of healthcare services, procedures, and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. The overarching goal, according to the government and managed care organizations, was to help ensure that patients were provided cost-effective, high quality, medically necessary care delivered in an efficient manner. Despite this goal, the relationships between managed care organizations (as well the PROs overseeing Medicare and Medicaid) and doctors and hospitals were still adversarial. UM strategies sought to avoid delays in treatment and in discharge from the hospital for inpatients, no matter what their disease or disorder. DRGs were still the payment system. Insurance companies invested large dollars performing, in a concurrent manner, medical record reviews while patients were hospitalized. UM nurses monitored each patient's hospitalization to ensure each day was medically necessary, there were no barriers to treatment or barriers to the patient being discharged to home or to a lower level of care, and the patient had a good clinical outcome. (Note that I used the navigation word barriers.)
Hospitals also employed UM nurses (many of whom were previously UR nurses) to review the medical record documentation daily during a patient's hospitalization. The UM nurses would contact the doctor if he or she identified any barriers to treatment or to discharge. The most common problem was lack of documentation in the medical records by the doctor to justify medical necessity for hospitalization on a given day. Keep in mind that up to this point, neither UR nurses nor UM nurses, at both outside organizations and hospitals, had any contact with the patients. In some situations, inhospital UM nurses were responsible for contacting the insurance carrier UM departments each day to report on the specific care being provided to justify each patient's stay for "1 more day." Quality of care was getting more attention; however, concern regarding patient safety was starting to surface. PROs in particular were monitoring care from a quality perspective, raising flags when a complication would occur that was felt to be avoidable. Such instances could result in a team of doctors and nurses coming to the hospital and conducting focused reviews of specific patient populations. The war continued between payers of care and deliverers of care.