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14 Cards in this Set
- Front
- Back
UM = UR + CM
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blank
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All UM includes:
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Reducing practice variation
Managing utilization Isolating special cases and using CM Using e-commerce |
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Difficulties of UM:
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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). |
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Reasons for Variations in Utilization Level
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geographic area
Poverty – poor utilize most morbidity physician practice variation technology physician financial incentives the MCO’s UM initiatives Type of plan |
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DEMAND MANAGEMENT
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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 |
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SPECIALTY SERVICES UTILIZATION REVIEW (UR)
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means controlling the number of services performed by SCP’s
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Reasons why Specialty Services are more expensive than Primary Services:
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higher fees
hospital- and procedure-intensive SCPs order extra diagnostic studies Secondary referrals |
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SCP Utilization Review Methods:
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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) |
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HOSPITAL / INSTITUTION UTILIZATION REVIEW (UR)
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Patients go to / stay in the hospital unnecessarily.
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Prospective Review Methods
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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 |
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Concurrent Review Methods
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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 |
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Retrospective Review Methods
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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 |
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ALTERNATIVES TO ACUTE CARE HOSPITALIZATION
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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 |
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CASE MANAGEMENT (CM)
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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. |