Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 34Utilization Management Version 3.0Medical Management GuideSample UM Data Elements or MeasuresOutpatient Measures Ancillary Measures Inpatient MeasuresAmbulatory procedures (CPT) per 1000MTF enrolled per month/per year• Identify procedures with the highestfrequency.• Is the highest frequency of a givenprocedure within the MTF or thePurchased Care System (PCS)?• If higher in the PCS, is that procedureavailable within the MTF? If yes,identify causes for referral andconsider strategies for recapturingcare.• Conduct a focused retrospective reviewto determine if the highest frequenciesmeet medical necessity criteria. If highnumbers do not meet the criteria,consider a short-term prospective reviewfor high frequency/high cost.ED encounters per 1000 MTF enrolledper month/per year• Identify high ED utilizers.• Consider CM, education, DM, andmarketing of an advice line.• Is there inappropriate use or overutilizationof the ED? Is there anaccess issue?• Are there implications for communityoutreach (e.g., is there a high volumeof fractures)?• Is there a pattern to the cause?• Which safety factors might be missingto prevent fractures?High volume ICD-9-CM principaldiagnoses for ED visits for MTFenrolled per month/per year• Identify the highest occurring principaldiagnoses within the ED.• Identify patterns by enrollee and by typeof visit. Consider CM, DM, etc.• Are there implications for communityoutreach (e.g., is there a high volumeof fractures)? Is there a pattern forthe cause?• Which safety factors might bemissing?Radiology procedures perMTF enrolled per month/peryear• Identify the highest volumeprocedures.• Are criteria availablethat must be met priorto ordering a high-costradiological procedure? Arethey being used?• Identify the referral rate tothe PCS if the procedure isavailable in house.• If unacceptable andinappropriate procedures arebeing ordered, determinewhether criteria exist toaddress the problem.• If there are existing criteria,ensure all providers areeducated in their use.• If not, consider forming ateam to develop criteria.MTF average length of stay (ALOS) per diagnosisrelatedgroup (DRG) per month/per year• Identify the overall MTF ALOS.• Identify the highest frequency DRGs and comparethem to the overall MTF ALOS.• Are one or more DRGs skewing the overall ALOS?• Compare MTF ALOS to external averages.• Is the MTF ALOS higher or lower?• Stratify by department/service (medical, surgical,maternity, newborn, behavioral health) and identifyproblem areas for further study.• Conduct a DRG-specific retrospective focused reviewto determine if discharge planning, CM, clinicalpathways, or other strategies are indicated foraberrant DRGs.Is concurrent review indicated for a brief periodto pinpoint barriers to timely discharge?Admission rate per 1000 MTF enrolled per month/per year• Stratify by MTF and PCS and compare admissionrates.• Identify the reasons for PCS admissions if your MTFhas the same inpatient resources.• Why are MTF beds unavailable?• Can steps be taken to decrease MTF LOS andincrease capacity?• What are the preventable admission rates?• Are there indications for CM, DM, etc.?• Stratify data by department/service. Select priorityand use the UM process to form an action plan.• Stratify by DRG and/or diagnoses to identify thetarget population for intervention.Top diagnoses for same-day surgeries withunplanned admissions for MTF enrolled permonth/per year• Consider reasons for the admissions.• Were any of these preventable?• Are there clusters or patterns to the preventableadmissions?• Is a quality review indicated?Fig. 9 – Sample UM Data Elements or Measures
Medical Management GuideVersion 3.0Utilization ManagementPage 35Sample UM Data Elements or Measures (cont.)Outpatient Measures Ancillary Measures Inpatient MeasuresICD-9-CM principal diagnoses seen withinthe outpatient setting for MTF enrolled permonth/per year• Identify the highest occurring diagnoses.• Stratify by medical, surgical, and behavioralhealth; and by adult/pediatrics.• Would group visits for select diagnoses beappropriate?• Are CPGs in use? Are they being usedcorrectly? Is provider education indicated?Procedures (CPT): Top high volume for MTFenrolled per month/per year• Identify the highest occurring procedureswithin the outpatient setting.• Stratify by adult and pediatric categories.• Conduct a focused review to confirm themedical necessity and appropriateness ofhigh-volume procedures.Specialty referrals per MTF enrolled permonth/per year• Stratify by referrals within the MTF andreferrals to the PCS.• If there is a high volume of referrals sent tothe PCS, determine contributing factors.• Reference Milliman Ambulatory CareGuidelines TM or InterQual® criteria.• Are these guidelines being used to assistPCMs?• Could the care be managed by the PCMs? IsPCM education indicated?Total discharges within 24 hours of an admission forMTF enrolled per month/per year• Distinguish inappropriate admissions (i.e., those that didnot meet medical necessity or level-of-care criteria).• Conduct a focused review to identify underlying causes.• Select appropriate strategies.• Was the observation level of care more appropriate?• Is that level of care available within the MTF?• Can you potentially designate certain beds asobservation-level?Top DRGs by RWP for all MTF enrolled per month/per year (Note: DRG Weight Table lists RWP for eachDRG)• Identify the highest frequency DRGs for the date range.• Identify the ALOS for individual DRGs.• Utilize the DRG weight table to identify relative weightsand LOS.• Stratify by department/service.• Are there patterns that warrant further investigation?• Are preventable admissions included in the topDRGs?• Are CM, DM, discharge planning, or other strategiesindicated?Total MTF admissions for enrolled population byprincipal diagnosis per month/per year• Stratify by department/service and key demographics.• Identify patterns and potential problem areas.• Compare admission diagnosis to principal diagnosis toidentify potential patterns (e.g., admission diagnosisis rule-out myocardial infarction while the principaldischarge diagnosis is gastroenteritis).• Conduct a focused review to confirm theappropriateness of targeted admissions.MTF readmission rate for same or related diagnosiswithin 30 days of discharge for MTF enrollees permonth/per year• Identify potential quality-of-care concerns.• Compare the first and second or subsequent dischargesfor a specific enrollee.• Were the first discharge or subsequent dischargespotential premature discharges?• Was the readmission related to insufficient dischargeplanning, patient education, or follow-up care?Fig. 9 (cont.) – Sample UM Data Elements or Measures
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