Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 12 Medical Management EssentialsVersion 3.0Medical Management Guidenumber of relative value units [RVUs]). Clinicalprofessionals will also be involved in implementingsome of the critical initiatives identified within thebusiness plan, such as RM and evidence-basedhealth care (i.e., DM). (See also IntegratingUtilization, Case, and Disease ManagementFunctions; Staffing for Combined Functions,later in this section.)Eight critical initiatives frame business planning inthe MTF:1. Improve Access to Care2. Improve Provider Productivity3. Manage Referrals4. Labor Reporting (performed through theMedical Expense & Performance ReportingSystem, or MEPRS: http://www.meprs.info/— see also Section V, Medical ManagementTools)5. Improve Documented Value of Care (Coding)6. Evidence-based Health Care7. Manage Pharmacy Expenses8. Expeditionary Planning (Readiness)To help MTF Commanders execute their localbusiness plans, the MHS has established MM as partof both its clinical and business operations. Businessplanning offers the opportunity for annual strategicmanagement by creating a defined relationshipbetween current performance and the criticalrequirements needed to reach market goals. Asa new resource allocation methodology, businessplanning forecasts healthcare needs within the DCSand PCS with budgets focused on outputs ratherthan inputs. MM measures are calculated at variouslevels within the MHS, with a number of sourcesthat centrally calculate and display measures fromService-level aggregate to provider-level detail.(See Section V, Medical Management Tools,for information and resources related to Tri-Servicebusiness planning.)INTEGRATING UTILIZATION, CASE, ANDDISEASE MANAGEMENT FUNCTIONSIntegrating MM components not only improvesclinical outcomes; it improves organizationalefficiency and effectiveness. For example, whilemore CM and DM personnel are used to implementcomprehensive and integrated MM programs,staffing needs shift as fewer direct UM-relatedauthorizations are needed.Integrating UM, CM, and DM functions in the MTFfacilitates transitions of care and stewardship ofresources. The National Transitions of Care Coalition(http://www.ntocc.org/) advocates for and hasdeveloped tools to support transitioning patients.Historically, MTFs placed UM within their BusinessOperations or Resource Management department,while CM and DM were placed within the Nursingdepartment. This produced significant fragmentationof services, higher staffing requirements, andincreased costs. It also generated the view,particularly among providers, that the priority of UMstaff was to save money for the institution ratherthan to provide safe and quality health care topatients.Current trends focus on co-locating UM and CMresources to maximize and balance both clinicaland business outcomes. Fully integrating UM andCM staff has helped improve the overall quality of
Medical Management Guide Version 3.0Medical Management EssentialsPage 13care through a highly synergistic effect, with thefollowing results:• Significant decrease in the duplication of effortand redundancy.• Decrease in negative outcomes from improperor poor handoffs.• Improvement of overall workload management.• Improvement in the appropriate patient use ofbenefits.UM, CM, and DM have many similarities in termsof goals, concepts, and tasks. The key to successis establishing links of communication betweenprograms or departments. In this regard, it is helpfulto consider these three MM components within thecontext of a healthcare continuum as described inthe 2001 DoD Population Health Improvement Planand Guide (next iteration due to be published in2011). The Guide is available at http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf (see alsoExecutive Summary, CD-ROM ResourceES-1).Continuum is defined as an uninterrupted period,referring to the various stages of health andapplications of the CM process. It may be seenas running parallel to a "preventive model" thatmeasures cause and effect in MM interventions.This model comprises three phases, as describedin part by Wilson, Carneal, and Newman (2008)(see CD-ROM Resource MME-12 for fullarticle):• Primary prevention is about preventing theonset, or incidence, of disease (e.g., throughvaccinations).• Secondary prevention is about detection ofdisease.• Tertiary prevention is about the prevention offurther suffering among end-stage prevalentcases (e.g., through ameliorating pain andproviding psychosocial comfort).Based on this model, success (achievement ofoutcomes) can be understood in one of two ways:• Slowing, halting, or reversing advancementwithin the same phase.• Slowing, halting, or reversing transition to thenext phase.Fig. 4 illustrates how UM, CM, and DM functionsinteract within the MHS in the context of thePopulation Health continuum and in keeping withthe three levels of prevention.While the end goal is to integrate the componentsof MM, MTFs may first need to developtheir individual UM, CM, and DM programs. Fig. 5compares and contrasts each component.Some challenges may prevent successfulintegration. For example, each Service — from theheadquarters to the local MTF level — organizesits medical services and departments differently,using a variety of titles, terms, and personnelresources. Additionally, there continues to be alack of process standardization within the Servicesthemselves. Identification of poor clinical outcomesor other red flags (e.g., an inability to meet accessstandards, longer lengths of stay, or outliers ofany performance measure) may indicate system ororganizational issues rather than a clinical problem.
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