Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 36Utilization Management Version 3.0Medical Management GuideThese criteria are not based on diagnosis butrather on the severity of the patient’s illness andthe intensity of the services required. Thus, theyserve as criteria for all hospital care, regardless oflocation or facility size. McKesson InterQual productsare packaged in criteria sets that are continuouslyevolving. The DoD licensing agreement providesWeb-based access, with online modules availablefor distance learning through the TMA PHMMDSupport Center at http://www.tricare.mil/ocmo.Milliman Care Guidelines ® — http://www.careguidelines.comThe Milliman Care Guidelines target conditionsordinarily seen by primary care managers (PCMs) inthe ambulatory care arena.The guidelines are published by Milliman in aWeb-based format and are accessed through itsCareWeb portal (http://www.careguidelines.com/login-careweb.htm). Access via CareWeb requiresa DoD account, which provides a username andpassword. Access is granted only to users employeddirectly by the MTF. For more information and logoninstructions, contact your local MTF or designatedTMA point of contact (POC).A Milliman Care Guidelines distance learning trainingmodule is available through the Population Healthand Medical Management Division (PHMMD)Support Center at http://www.tricare.mil/ocmo.( CD-ROM Resource UM-3 shows screenshotsand provides descriptions of various Millimanresources.)These guidelines:• Provide clinical detail about diagnostic andtherapeutic approaches, and about referralsand procedures.• Introduce and integrate pharmaceutical andmanagement considerations.• Define the assessment and treatment modalitiesthat should occur at the primary care level priorto referral for specialty care.• Help PCMs provide the fullest spectrum of careat the most appropriate level, while helping theMTF conserve specialist resources.The guidelines are not intended to be used withoutthe judgment of a qualified healthcare providerwith the ability to consider each patient’s individualcircumstances. They are updated every one to twoyears, or as necessary, to reflect industry changes.Provider ProfilingProvider profiling can be defined as theidentification, collection, collation, and analysis ofdata to develop a provider-specific characterizationof performance. The process represents animportant application of analytics to improve qualityand reduce costs. The data analysis that results fromprovider profiling gives providers a more completepicture of the quality of care they provide.Provider profiling can be tailored to meet specificneeds based on the healthcare delivery model.According to Kongstvedt (2007), profiles shouldshare the following characteristics:• Accurately identify the provider in the profile.• Accurately identify the specialty of the provider.• Help improve the process and outcome of carein both dollar and quality outcomes.
Medical Management GuideVersion 3.0Utilization ManagementPage 37• Have a firm basis in scientific literature andprofessional consensus.• Meet certain statistical thresholds of validityand reliability.• Compare the provider to the norm.• Cost the minimum amount possible to produce.• Respect patient confidentiality.When profiling a provider, consider the level ofanalysis involved. Profiling at the individual providerlevel is often not possible because the numberof episodes for each physician is too small. Theresulting statistical instability introduces too mucherror to generate robust comparative conclusions.Instead, profiling should be performed at theclinic/group level. This also has the advantage oftaking into account the fact that care is deliveredby teams of providers, particularly for complex andchronic diseases.Referral ManagementReferral Management (RM), considered a subcomponentof a UM program, is the process ofmanaging and tracking internal/external patientreferrals within the MTF, to another MTF (i.e., withinthe DCS), or to network specialists (i.e., to thePCS). RM provides a mechanism for determiningpatient access to specialty clinics, durable medicalequipment (DME), and network inpatient admissionsthat use evidence-based criteria and predeterminedclinical/business outcomes.RM is an important business and clinical processwithin the MHS. It provides a clear capability tominimize costs for care referred to the network.RM goals are to promote continuity of care,timely intervention, access to care, recapture careappropriately, and make informed decisions aboutthe most effective utilization of resources.MTFs hold primary responsibility for coordinatingthe tracking and closure of specialty referrals fortheir enrolled population. A referral is the processof directing an MHS patient from one healthcareprovider to another within the DCS, or to a network(preferably) or non-network (as necessary) civilianprovider. A referral request is expected in mostcases; in some circumstances, a preauthorizationmay be required. A consult report, known as aClearly Legible Report (CLR), is the primary methodused to close out a referral.The RM process involves two types of component:clinical and administrative.The clinical component includes performing URfor medical necessity of specialty referrals anddetermining appropriateness of care. RM staffshould apply the use of approved clinical practiceguidelines (CPGs) and proactively identify and referpatients for CM or DM.The use of clinical practice guidelines (CPGs) canfacilitate the RM process, since recommendedreferrals for specialty care are included withinthe practice guidelines (see Section IV, DiseaseManagement, and Appendix C, Definitions,for more information on CPGs). The ability to verifythe appropriateness of a referral for a particulardisease or procedure is available as a function inMilliman Ambulatory Care Guidelines (http://www.careguidelines.com/brochures/ac/ACebrochure.pdf)and McKesson InterQual evidence-based decision
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Medical Management Guide, 2009, Version 3.0 - Tricare

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