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14 Cards in this Set

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UM = UR + CM
blank
All UM includes:
 Reducing practice variation
 Managing utilization
 Isolating special cases and using CM
 Using e-commerce
Difficulties of UM:
 Hard to know if treatment is “medically necessary”
 hard to measure its effect (ROI)
 hard to collect utilz data
 requires an authorization system and grievance system
 disclosure to patients
 blurring of PCP and SCP roles
 Natural utilization variation (below).
Reasons for Variations in Utilization Level
 geographic area
 Poverty – poor utilize most
 morbidity
 physician practice variation
 technology
 physician financial incentives
 the MCO’s UM initiatives
 Type of plan
DEMAND MANAGEMENT
Activities designed to reduce members’ requirement for health care
 Nurse Advice Lines
 Self-Care programs
 Shared Decision making
 Medical Informatics
 warning: Internet is unregulated
 Preventive Services and health risk appraisals

Advantages of Demand Management:
 member satisfaction
 ROI
SPECIALTY SERVICES UTILIZATION REVIEW (UR)
means controlling the number of services performed by SCP’s
Reasons why Specialty Services are more expensive than Primary Services:
 higher fees
 hospital- and procedure-intensive
 SCPs order extra diagnostic studies
 Secondary referrals
SCP Utilization Review Methods:
Refer patients to the most cost-efficient SCPs
use higher copays for SCPs than PCPs (to discourage patients from using them)
use PCP to deliver specialty care
 cheaper, but PCP’s uncomfortable

use Authorization Systems
 use PCP as gatekeeper
Adv:
 cost control
Disadv:
 physs complain about administrative hassle
 patient access is reduced

 use flexible gatekeeper
Disadv:
 increases antiselection against these SCP's

 Allow Single-Visit Authorizations only
 except for treatments requiring repeated visits
Adv:
 best cost control possible
Disadv:
 difficult to enforce
 some laws require direct access

 Prohibit secondary referrals

 Chart Review and Referral Review
 pattern analysis
 chart reviews
 check form and quality of the referral
 was e-commerce used?

Uses:
 Training programs, questionable referrals

Disadv:
 Grossly cumbersome; expensive
 Demeaning to PCP's

 Deal with "self-referrals" by members (maybe grant one exemption)
HOSPITAL / INSTITUTION UTILIZATION REVIEW (UR)
 Patients go to / stay in the hospital unnecessarily.
Prospective Review Methods
 Precertification
 A target LOS is assigned.

Adv:
 prevents unnecessary admissions
 makes sure hospital is the appropriate setting
 allows preparation for discharge.
 incurral date is captured.

 Preadmission Testing and Same-Day Surgery

 Mandatory Outpatient Surgery for certain procedures
Disadv:
 no standard list of such procedures
 hosps can overcharge for outpatient
Concurrent Review Methods
 Maximum LOS
 depending on the diagnosis.
 costs beyond that day are not covered.

Adv:
 can be used over large geog. area
 requires fewer UM personnel
 doesn’t require negotiation.

Disadv:
 difficult to select the Max LOS
 diagnosis c/b inaccurate
 comorbid conditions not adjusted for
 physicians tend to use the maximum time allowed

 Rounding
Adv:
 can watch for quality problems
 better coordination of care
 planning for discharge
 patient satisfaction / comfort

Medical Personnel’s Roles (Responsibilities) in Concurrent Review:
Role of the UM Nurse
 Rounding
 Info gathering
 informing patient and family
 Reviewing the case against established criteria
 Discharge planning


Role of the PCP
 Rounding
 Coordinating patient's care
 discussing the case frequently with the SCP
(minus one point if you fail to italicize “frequently” on the exam)

Role of the SCP
 interact with PCP (should not second-guess him)
 Difficulty: SCP’s have less time & familiarity with the case. PCP better.

Role of the Hospitalist (Hospitalist Model)
Advantages of using a Hospitalist:
 efficient (always in the hospital)
 better coordination of services
 more timely diagnoses

Disadv:
 SCP and PCP lose control over the case


Role of the MCO Medical Director
 Deal with uncooperative physicians, Hospitalists, and patients
Retrospective Review Methods
 Claims Review
Examine claims for:
 upcoding; unbundling
 mistakes
 all large claims.

 Pattern Review
 find hospitals with the best: LOS, costs, clinical outcomes

 provide Feedback to providers
ALTERNATIVES TO ACUTE CARE HOSPITALIZATION
 Subacute Care: Skilled Nursing Facilities (Nursing Homes)
 Discuss nursing homes with patient and family
 must Communicate end of plan coverage
Uses: For long recoveries
Adv Cheaper than hospital
Disadv: Stigma attached; affects MCO’s marketability

 Step-Down Units
 A ward in the hospital that's a lot like a Skilled Nursing Facility
Adv: convenient for rounding
Disadv: costs more than a nursing home

 Outpatient Facilities
 Hospices
 Home health care
Uses: for quick procedures like changing bandages
Disadv: PCP and UM Nurse seldom visit; Home nurse might not make best
decisions
CASE MANAGEMENT (CM)
CM involves:
 identifying and managing especially-high-cost cases
 being proactive
 longitudinal coordination among providers
 use of community resources
 going beyond plan benefits in order to reduce care costs.


Done.