Medical Management Guide, 2009, Version 3.0 - Tricare

More documents

Recommendations

Info

Page 76Case Management Version 3.0Medical Management GuideExamples of CM Measures• Timeliness of service• Cost avoidance to the Direct Care System(DCS)• Relative Weighted Product (RWP)/RelativeValue Unit (RVU) impact of a CM intervention• Recaptured care as a result of CMcoordination• Access to specialty care services as a result ofCM coordination• Beneficiary satisfaction• Reduced hospital admissions• Patient knowledge of the healthcaretreatment plan and benefits• Improved provider/patient interaction• Measures of clinical improvement• Appropriate utilization after CM intervention• Hospital readmissions rate before and afterCM interventionFig. 21 – Examples of CM MeasuresOutcome measures validate:• What is effective.• What is not effective.• The cost of an intervention.• Return on investment (ROI).A cost-benefit analysis is performed to helpdetermine a) whether to make a change or b) howwell a planned action (e.g., implementation of aprogram) may turn out.A cost-benefit analysis relies on adding up positivefactors and subtracting negative ones to determinea net result. The technique is to simply add up thebenefits of an action/intervention and subtractthe costs associated with that action/intervention.The cost-benefit analysis is closely linked to the“evaluation” aspect of the CM process. As thecase manager coordinates services and makesrecommendations for care options, he/she shouldconduct an ongoing cost-benefit analysis regardingthose choices.Another method of demonstrating value is totrack and calculate costs that were avoided.Using a log to collect data of your caseload is astraightforward method for expressing quantity andcost effectiveness. (Refer to CD-ROM ResourcesCM-18, CM-19, and CM-20 for examples of CMcaseload logs.)According to Kongstvedt (2001), a cost-benefitanalysis report for CM should include the followingelements:• Overview of CM intervention (a brief narrative).• Summary of intervention.• Actual charges.• CM fees.• Savings (e.g., avoided or potential charges;discounted and negotiated reductions;reductions in services, products, and/orequipment).• Gross savings (potential charges minus actualcharges).• Net savings (gross savings minus CM fees).• Status of the case (opened or closed).
Medical Management GuideVersion 3.0Case ManagementPage 77CM Hard and Soft SavingsHard Savings or Avoided Costs*• Change in the level of care facilitated by CM• Change in the patient’s length of stay (LOS)• Change to a contracted PPO provider• Finding unauthorized charges that are notwarranted• Negotiation of duration of services• Negotiation of frequency of services• Negotiation of price of services, supplies, equipment,or per diem rates• Prevention of unnecessary bed days, supplies,equipment, services, or chargesSoft Savings or Potential Savings**• Avoidance of potential acute care days• Avoidance of potential costs, equipment, andsupplies• Avoidance of potential ED visits• Avoidance of potential home health visits• Avoidance of potential hospital admissions• Avoidance of potential legal exposure• Avoidance of potential medical complications• Improved patient/family satisfaction with CM• Improved patient compliance• Improved quality of care or quality of life*Measurably saved or avoided costs when facilitatedby the case manager.**Less tangibly measurable than hard savings.If no case manager was assigned to the patient,the potential costs incurred could have beenmuch more than with CM; they represent coststhat were avoided most likely because of CMintervention.Source: Powell and Ignatavicius, 2001Fig. 22 – CM Hard and Soft SavingsCost-benefit analysis takes into account both hardand soft costs incurred as a result of a selectedoption for care or a choice in service delivery.hours of care, preventing unnecessary bed days,or reducing the unnecessary use of supplies andequipment.Hard costs (or hard savings), also known as “avoidedcosts,” are measured in actual dollars when costsare measurably saved or avoided (Powell andIgnatavicius, 2001). Examples of hard costs mayinclude such items as hospital bills, physician fees,and medical supplies in which the case managerfacilitated a change in the level of care, the patient’slength of stay (LOS), or negotiated the frequencyor duration of services. Hard costs can show clearsavings as a result of eliminating duplication ofservices, reducing Emergency Department (ED)visits, transferring to lower levels of care, reducingSoft costs (or soft savings), also referred to as“potential savings,” are factors that may not havean exact dollar measurement but that incur a socialor personal cost to the patient. Examples of softcosts are lost duty time, avoided ED visits, reducedproductivity, and improved quality of life.Fig. 22 describes CM hard and soft savings.
Page 2 and 3:
Instructions:When accessing this Gu
Page 6:
Page viExecutive SummaryVersion 3.0
Page 9 and 10:
Medical Management Guide Version 3.
Page 11 and 12:
Page 13 and 14:
Page 15:
Page 20 and 21:
Page Medical Management Essentials
Page 22:
Page Medical Management Essentials
Page 25 and 26:
Medical Management GuideVersion 3.0
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39:
Page 44 and 45: Page 26Utilization Management Versi
Page 66 and 67: Fig. 11 (cont.) - MTF Review and Ap
Page 72: Page 54Utilization Management Versi
Page 76 and 77: Page 58Case Management Version 3.0M
Page 118 and 119: Page 100Case Management Version 3.0
Page 123 and 124: Medical Management GuideVersion 3.0
Page 145 and 146:
Page 147 and 148:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Page 199 and 200:
Page 201 and 202:
Page 203 and 204:
Page 205 and 206:
Page 207 and 208:
Page 209 and 210:
Page 211 and 212:
show all

Medical Management Guide, 2009, Version 3.0 - Tricare

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?