Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 28Utilization Management Version 3.0Medical Management Guide1. Identify the PurposeStep 1 is to identify priorities for focus andexamination. Priorities evolve from utilization data,suspected problem areas, MTF strategic goals,Command initiatives, and directives from an MTF’sService Branch and/or other higher authority. Whendefining priorities, UM staff should solicit input fromall departments/services within their MTF.2. Determine What to Measurewhen the patient has been prescribed sevenor eight concurrent medications), unexpectedadmissions, or death following ambulatorysurgery.Utilization measures facilitate the MTF’s ability to:• Identify Service Branch-specific areas for focusedUR.• Develop reports that display the applicable dataelements for study.• “Drill down” for patterns of care.Step 2 is to select measures (i.e., metrics) and collectdata relevant to the MTF — this despite the fact thatthere is no higher-level mandate to obtain a specificset of measures.Utilization managers should select measures andcollect data based on priorities. Typically, thesemeasures relate to:• High-cost, high-volume, or “problem-prone”diagnoses, procedures, and services.• Patients who have demonstrated high utilizationrates.The definition of what constitutes a problem-pronesituation varies by setting. For example:• Inpatient services — Refers to diagnosesincluding those related to high mortality, highmorbidity, prolonged length of stay (LOS), highreadmission rates, and preventable admissions.• Ambulatory services — Includes multiplevisits for the same condition across varioussettings (e.g., primary care clinic, EmergencyDepartment [ED], specialty care) or with multipleproviders. Also includes polypharmacy (e.g.,A data query can either focus on a particular,identified problem or issue (e.g., number of ED visitsin the MTF and network during the past year forall Active Duty Service members [ADSMs]); or beexpanded to include a broad range of data elements(e.g., all inpatient and outpatient visits for the pastyear for all patient categories) that might helpidentify potential trends or patterns of care that givecause for concern. (See also Section V, MedicalManagement Tools.)If the data include a general range of elements, it isbest to sort those data into categories to distinguishwhere problems may lie. For example, one table orreport may list high-cost, high-volume, or problempronediagnoses and procedures for patients withdemonstrated high-cost, high-volume, or highlycomplex utilization patterns (i.e., “high utilizers”).Your data must make sense to the people who arereceiving the information and be considered valid(Hospital Peer Review, 2008).Categories are used to present data clearly. Theydo not imply that ambulatory care facilities shouldstudy only outpatient data; an ambulatory care
Medical Management GuideVersion 3.0Utilization ManagementPage 29facility might evaluate inpatient admissions to thePurchased Care System (PCS) to identify opportunitiesfor cost savings or coordination of care.UM staff should remember that they are not alwaysexpected to perform the role of data miner. Rather,they need to identify who has access to data (e.g.,M2 users, data analysts, decision support staff) andpartner with them by asking what is really going toaffect patient care, who needs to be involved, andhow to make the process a priority for decisionmakers(Hospital Peer Review, 2008).3. Determine the Gapsand tertiary preventive interventions (seeSection I, Medical Management Essentialsand Appendix C, Definitions). This can helpUM staff identify and refer patients who mightbenefit from specific management strategies,such as CM or DM. When evaluating data relatedto a particular occurrence, priorities will varyfrom facility to facility. Staff in a smaller MTFmay elect to focus on their five most frequentlyperformed procedures, while staff in a larger MTFmight study their 10 or even 15 most frequentlyperformed procedures. Alternatively, MTF staffmight focus on the most problematic or prevalentdiagnoses rather than the most frequent.Step 3 is to determine the gaps, if any, betweenactual and desired conditions. Identify:• Any red flags or undesirable trends andvariations from internal/external benchmarksand comparative data.• Other potential areas for process improvement.When comparing MTF performance to nationalbenchmarks, you must take into account differencesbetween the MHS and the civilian health system(notably the unique MHS benefit, funding structure,military mission, diverse healthcare environments,and population distribution). You must also considerrisk adjustment and severity of illness (i.e., througha case mix index) when comparing an MTF to acivilian facility or comparing one MTF to another.4. Attempt to Fix the Problem(s)Step 4 is to attempt to fix the problem(s) byprioritizing opportunities for improvement based onthe MTF’s strategic goals, population needs, qualityinitiatives, and patient safety considerations. Hereit is important to focus on areas with the greatestcost-to-benefit ratio and the highest probabilityfor success. When evaluating which processes toimprove, be sure to consider whether or not theapplicable measures are reliable and valid. Whenreviewing those measures, consider where you canrealize improvements within the data systems ordata collection and reporting processes to ensuredata accuracy and reliability, which, in turn, affectsdecision-making.By drilling down further, MTF staff can identifyhigh-volume diagnoses, procedures, and services;and individual patients with high utilization rates.They can then define significant trends anddetermine where to focus primary, secondary,Formulate an action plan and attempt to fix theproblem, which involves selecting appropriatestrategies to address each priority stated in the UMprogram. This plan should include milestones anddelineate individuals or departments responsible formeeting those milestones.
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Medical Management Guide, 2009, Version 3.0 - Tricare

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