Medical Management Guide, 2009, Version 3.0 - Tricare

Medical Management GuideVersion 3.0Medical Management EssentialsPage Medical Management EssentialsSECTIONIINTRODUCTIONDefinition of Medical ManagementIn the healthcare industry, organizations haveestablished programs or systems to improveclinical outcomes and manage rising healthcarecosts. This is broadly referred to as the field of“Medical Management” (MM).The 2006 Department of Defense Instruction (DoDI)6025.20, Medical Management (MM) Programs inthe Direct Care System (DCS) and Remote Areas( CD-ROM Resource MME-1, and http://www.dtic.mil/whs/directives/corres/pdf/602520p.pdf)defines MM as an “integrated managed care modelthat promotes Utilization Management (UM), CaseManagement (CM), and Disease Management (DM)programs as a hybrid approach to managing patientcare.” MM includes a shift to evidence-based,outcome-oriented programs that place “a greateremphasis on integrating clinical practice guidelinesinto the MM process, thereby holding the systemaccountable for patient outcomes” (DoDI 6025.20).This guide provides specific, how-to guidance onestablishing MM programs within Military TreatmentFacilities (MTFs) in accordance with the DoDinstruction.The three components of MM are commonlydefined as follows:• Utilization Management: An organization-wide,interdisciplinary approach to balancing cost,quality, and risk concerns in the provision ofpatient care. UM is an expansion of traditionalUtilization Review (UR) activities to encompassthe management of all available healthcareresources, including Referral Management (RM).• Case Management: A collaborative processunder the Population Health continuum thatassesses, plans, implements, coordinates,monitors, and evaluates options and servicesto meet an individual’s health needs throughcommunication and available resources topromote quality, cost-effective outcomes.• Disease Management: An organized effort toachieve desired health outcomes in populationswith prevalent, often chronic diseases forwhich care practices may be subject toconsiderable variation. DM programs useevidence-based interventions to direct patientcare. DM programs also equip the patient withinformation and a self-care plan to managehis/her own health and prevent complicationsthat may result from poor control of the diseaseprocess. The term “condition management”includes non-disease states (e.g., pregnancy).See also Appendix C, Definitions.