Utilization Management

1. Utilization Management Edward F. Crooks MD, CMQ, CLSSBB

2. Utilization Management History • Formation of the AMA in 1847 – American medicine was disorganized and of poor quality. • 1914 Earnest Codman recommended that each physician and hospital should be accountable for the outcomes of their patients. • This influence the ACS to establish the Hospital Standardization Program (1917). • Organizing hospital medical staffs • Limiting staff to well-educated, competent and licensed physician. • Framing rules and regulation to ensure regular staff meetings and clinical review. • Keeping medical records that included the history, physical examination and laboratory results • Establishing supervised diagnostic and treatment facilities

3. Utilization Management • In the 1953 the ACP, the AHA, and the CMA joined with the ACS to form the Joint Commission on Accreditation of Hospital Organization. Mandated peer review • In 1965 the Congress pass Title XVIII of the Social Security Act.Enacted certain conditions of participation in Medicare witch included utilization review. • In 1972 the Professional Standard Review Organization (PSRO) came in to existence through amendment to the Social Security Act. Responsible to promote efficiency and try to eliminate unnecessary hospital utilization.

4. Utilization Management • In 1982 the PSRO was replaced by the Peer Review Organization (PRO). Mandated to validate DRG coding, to reduce unnecessary hospital admissions and operation and to improve quality of care in the hospital. • 2002 the PRO was renamed Quality Improvement Organization (QIO). Major organization that will improve quality and efficiency of health care for Medicare beneficiaries.

5. Utilization Management Critical Components of UM • Utilization data and information that can be easily compared • Continued improvement in UM process. • UM need to use up-to-date technology • Safeguards to protect individual patient data and information (HIPAA). • UM must utilize evidence-based medicine, patient and provider satisfaction measures, cost of operations, and clinical outcomes of patientto determine the appropriateness and success of UM efforts. • Determination must be reliable, consistent and follow the policy of the UM program.

6. Utilization Management • UM must be responsive to patients and providers through grievance and appeals program, quality monitoring system, and trending of the decisions of care. • UM must occur without delay – there need to be process in place that reviews alternative of care, placement of care and providers of care in a timely fashion.

7. Utilization Management The Nine Tasks Key to Effective UM • Determine Priority Areas • Identify Needed Information and Critical Stakeholder • Establish Appropriate Benchmark • Design Data Collection, and Data Management Procedures • Implement Data Collection, and Data Management Procedures • Evaluate the Data and Present the Results • Develop Guideline, Policies and Procedures • Implement Guidelines, Policies and Procedure • Continuously Review task List

8. Utilization Management UM Process • Pre-authorization • Make sure that the clinical intervention is appropriate and takes place in the right setting and time, and the clinician has the expertise to do the clinical intervention. • Concurrent Review • Management of resources by evaluating the necessity, appropriateness, and efficiency of the use of medical services, procedure and levels of care while a patient is in a facility • Milliman Care Guidelines and Qualis Health-Mckesson’s InterQual Criteria • Retrospective Review • Process of reviewing health care interventions and charges after the care has been delivered and the bill is submitted.

9. Utilization Management Interrater Reliability • UM process has the potential to be evaluated by different reviewers therefore an interrater assessment is required. • IR assessment is defined as the process of monitoring and evaluating clinical reviewers’ understanding of medical review criteria and the consistency with which different reviewers apply the same criteria. • IR assessment is needed to certify that the review process decisions are made in a consistent manner according to evidence-based medicine criteria • Performed quarterly or semi-annually • Reviewers whose decisions are not consistent with the criteria are usually re-educated or re-tested.

10. Utilization Management Measuring the Effectiveness of UM Programs • Usually measured in financial terms, dollar savings or ROI. • Based on the following: • Evidence-based criteria • Reliable, accurate, and defensible data that has been validated. • Appropriate clinical expert review • Transparent methodology of effectiveness calculations.

11. Utilization Management Challenges in the Calculation of Effectiveness of UM • The sample size may be small or not appropriate for comparison • The sample population may be different by demographics, severity or culture. • There are no standardized methodologies across health care organization on how to calculate ROI.

12. Utilization Management • UM should be part of a group interventions to decrease overuse, underuse and misuse of health care and to improve individual and population outcomes. • There should be a system in place that can identify patient safety issues that have been avoided, by doing concurrent review in the hospital or identification of a quality problem that was reported before it became a major issue. • UM process may also enhance the patient experience with the health care system because of discharge planning and follow-up when the patient is out of the hospital.

13. Utilization Management Risk Management • Defined as identifying circumstances that put patients or an organization at risk for adverse outcomes and putting into operation methods that avoid, prevent, and control risks. • Was adopted by hospital when JC added sentinel event monitoring to the accreditation process in the mid 90s.

14. Utilization Management Organizational Design of UM • Personnel responsible for UM • UM must have clinical input from practitioners who must comply with the UM program. • Can have outside clinicians to evaluate the validity and appropriateness of the UM plan (UM committee or practitioner advisory committee • Senior Physician should lead the UM committee • UM committee should included several physicians from different specialties and primary care. • Meeting should be held regularly. • The HCO may also designate senior administrative leaders to serve on the committee • The committee should report to the decision makers in the HCO.

15. Utilization Management Function of the UM Committee • Design and development or planning • Program structure design • Identify opportunities to improve • Identify performance indicators and metrics • Align with organizational strategic plan • Monitor the review activity • Review progress of initiatives • Develop senior leaderships • Track accreditation preparation • Communication with appropriate internal and external stakeholders • Resource utilization progress • Program impact to workforce and senior leadership • Hold meetings to present results • Recognize and reward efforts • Program evaluation • Develop Um program evaluation measures • Ensure accountability for program goals and objectives • Present impact report

16. Utilization Management Disease Management • Defined as a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts can significantly improve health care outcome. • DM emphasize prevention of exacerbation and complications by the application of evidence-based medicine approaches.

17. Utilization Management Characteristics of DM • Support of the physician or practitioner-patient relationship and plan of care. • Stratification of patients by risk level • Evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health for the individual • An intended outcome of better patient self-management over time.

18. Utilization Management Six Components that a full-service DM must have • Population identification process • Evidence-base practice guidelines • Collaborative practice models that include physician and support service providers • Patient self-management education including primary prevention, behavior modification, and compliance evaluation • Process and outcome measurement evaluation and management • Routine reporting-feedback loop including communication with the patient, the physician, and other identified stakeholders under HIPAA regulations

19. Utilization Management Methods of communication • Telephone calls • Text Messaging • Web-based communication

20. Utilization Management Standardization of ROI • Care Continuum Alliance (formerly Disease Management Association of American) • NCQA

21. Utilization Management Most common DM Programs for commercial populations are: • Diabetes Mellitus, • Congestive Heart Failure • Asthma • Cardiovascular Disease, • Low Back Pain and • Depression

22. Utilization Management There is movement to cluster related diagnosis and chronic condition together to create a more comprehensive program: • Asthma and COPD • Hypertension and CAD • Diabetes, CHF and hyperlipidemia

23. Utilization Management Disease Management • Should be built for population being served by careful analysis of the diseases that the population has been diagnosed with and the drivers of cost and quality for that population • The process of evaluation should be ongoing to identify and to adjust for changes in the demographics and use of health care so that new programs can be implemented.

24. Utilization Management Case Management • Defined as centralizing the planning, arranging, and follow-up of a member’s specific health services in order to manage utilization, effectiveness, cost, and quality health care. • Use to monitor and coordinate medical and other services rendered to members (special populations) who have specific diagnoses, high cost or intensive services. • Coordinates designated component of health care. • Help patient with social and environmental concerns that may hinder or delay improvement in the medical condition.

25. Utilization Management • Helps patient navigate through complex systems or different organizations and avoid fragmentation or mis-utilization of services. • Works at the individual patient level and communicates frequently with the patient and the provider of care.

26. Utilization Management Key Components of Case Management Program: • Screening and identification of conditions, populations, individual patients, and disease states for early detection of health problems. • Identifying and implementing effective interventions for individual using evidence-based medicine and removing social-environment barrier to care. • Promoting and coordinating a collaborative team approach across various disciplines and levels of care.

27. Utilization Management Key Components of Case Management Program: • Coordinating continuity of care through the course of the disease or condition to attain the best possible clinical outcome and improve quality of life. • Coordinating support and education for the patient, patient’s family, and others involved in the patient’s care to improve and sustain self-management behaviors and quality of life. • Ensuring that all the providers of care and the patient know the care plan, have input into the care plan, and get regular report on the progress of the patient according to the care plan.

28. Utilization Management Care Plans • Used for DM and case management • Plan for DM is usually a general plan of care that is applicable to a large population with one disease or condition • The care plan for case management is usually individualized for the patient.

29. Utilization Management Care Plan Development • Identify the patient who needs a case management care plan. • Assign a case manager • Identify the diagnosis of the patient, how the case was referred. • Initiate patient assessment. • Coordinate with providers of care after the assessment to determine their input to the assessment and a plan of care. • Develop a care plan, utilizing the inputs from the patient, provider, and other identified stakeholders of the patient. • Patient-identified areas for improvement. • Motivation to improve. • Provider identified milestone of care that will get the member to the best outcome. • Identify processes that remove nonclinical barriers to the success of the patient and the care plan.

30. Utilization Management • Communicate the care plan to patient, provider and other stakeholders under HIPPAA requirements and get their sign off. • Continuously update the care plan and the progress made, changing it as needed with inputs from the patient, the provider and the stakeholders. • Identify timeline and outcomes for the complete case management care plan.

31. Utilization Management Web-Based System • Success in meeting the case management goals and objectives can be made easier if a Web-based system is used to produce, to disseminate, and to update the care plan. • Often patients who are identified in DM get rolled into case management because their disease process becomes so severe that they need individual case management to improve. • Conversely patients who are finished with CM get rolled into DM program because their underlying disease is not cured and the patients continue to need self-improvement strategies.

32. Utilization Management Demand Management • Includes the activity and interventions specifically designed to improve the appropriateness of members’ use of health care resources. • It may include: • member self-management, • stepped care programs, • other utilization processes • community and stakeholder outreach

33. Utilization Management Demand Management is implemented through the following activities; • Providing health information to the patient through calls, faxes, email, the Web, et cetera • Offering preventive services that follow evidence-based guidelines • Providing case management, disease management, and other supportive services • Evaluating the health risks of patients and newly insured patients to identify preventive intervention and self-care capabilities • Partnering with community resources to promote the use of local and national programs that can improve health and wellness. • Monitoring the utilization of a patient’s services to identify the need for intervention such as care coordination.

34. Utilization Management Demand Management • Ongoing process for patient with or without a specific chronic disease. • Can be layered on top of CM, DM and other UM processes – be aware of duplication. • May increased the cost of care by helping the patient improve their use of health care interventions • Demand management is utilized for all of the population in the benefit plan – it is a process of communication for a population needing similar or same services. • Demand management program sent to parents of 3- 6 year old to get their required immunization. • Contact all beneficiaries with an established diagnosis of diabetes to get their yearly exam.

35. Utilization Management Case management programs target individuals with chronic and/or catastrophic disease – is not for a population but for that specific patient with an individualized care plan.

36. Utilization Management Peer Review • The evaluation of the necessity, quality, cost, and /or utilization of care-service provided by a HC Professional-Provider • It is performed by HCPs or providers from the same discipline who are not in direct economic competition with the HCP. • Compares the HCP-provider’s performance with evidence-based medicine, his/hers peers within the same specialty with similar patients, and examines if the health provider’s action is within the scope of medical or insurance benefit of the patient. • Peer review regulatory requirements may vary from state to state. • Trending and tracking the accumulation of occurrences or potential occurrences that may warrant review by a peer or a UM committee, should take place during the peer review process.

37. Utilization Management • There is standard for frequency of similar issues or severity of a clinical intervention that would initiate a peer review. • Each organization should develop its own indicators, monitors and benchmark for peer review. • Peer review is usually protected as confidential information and should not be released outside of the person or body conducting the peer review. • The Health Care Quality Improvement Act of 1986 has given peer review an immunity protection, which may vary according to state law.

38. Utilization Management The following steps may be used in the process of peer review: • Identification of an issue or trend needing peer review from an internal or external source. • Request for medical records and additional information so a comprehensive review can take place. • Specific dates of information flow to take place from the provider and the reviewer. • Review of documentation by appropriate peer • Reviewer identifies a decision using evidence-based, individual patient condition, and other identified criteria • Reviewer decision is sent to UM committee for their input and decision. • Decision is sent to the provider for response and corrective action plan. • Provider being reviews is informed of his/her appeal rights.

39. Utilization Management Credentialing • The process of obtaining, verifying and assessing information to determine the qualification of a health care professional to provide services to patient. • It examines the training, education and the actual experience of the HCP. • May include data such as the number of times a surgeon has performed a certain procedure and the clinical outcomes for the patient. • Criteria for credentialing are well outlined by many organizations: • Joint Commission • URAC • NCQA

40. Utilization Management The following are the general process involved in credentialing: Primary Source verification • Medical School Graduation • Residency • Specialty Boards • State License • Drug Enforcement Certificate • History of Professional Liability • Clinical Privileges • Malpractice Insurance • Work History

41. Utilization Management Application and attestation • Reason for any Inability to Perform Essential Clinical Functions • Lack of Present Illegal Drug Use or Chemical Dependency • History of Loss of License – Felony Convictions • History of Change in Privileges or Disciplinary Action • Correctness and completeness of Application Verification • National Practitioner Data Bank • Health Care Integrity and Protection Data Bank • Licensure Limitation • Medicare and Medicare sanctions Initial Site Visit • May Be Required for Primary Care Physicians and some specialists.

42. Utilization Management Criteria for Credentialing • Using the above criteria, credentialing is an up-front process that protects patient, health care systems and physicians form potential quality and utilization issues. • Credentialing can be broken down into two processes • Contracting Component – determines whether the physician meets the criteria to have a contract with the health system. • Clinical appropriateness of the physician to have privileges to care for specific types of patients and/or diseases

43. Utilization Management Physician Profile • Summary of data and information specific to a physician or practice, compiled electronically from multiple data sources and appropriate methodology. • The data is severity adjusted for the group of patients the physician is seeing and is included in his profile. • Adjustment is made for outliers that could cause the physician profiles to be inaccurate because of the impact of high cost, high risk or other uncontrollable situations • The profile is used to compare utilization, quality and outcomes of an individual physician or group of physicians with their peers in a similar geographic area.

44. Utilization Management Accreditation and Regulatory Oversight of Utilization Management • UM are subject to regulatory oversight that ensures that they are not limiting or inappropriately denying the use of health care by patients. • The federal government has specific requirements for participation in Medicare that pertain to UM programs by vendors. • Accrediting organizations include, but are not limited to, Joint Commission, the URAC, the American Association of Ambulatory Health Care (AAAHC), and the NCQA

45. Utilization Management NCQA’s 2008 Health Plan Standards and Guidelines • A utilization management structure • Clinical criteria for UM decisions • Communications services • Appropriate professionals • Timeliness of UM decisions • Clinical information • Denial notices • Policies for appeals • Appropriate handlings of appeals • Evaluation of new technology • Satisfaction with the UM process • Emergency services • Procedure for pharmaceutical management • Triage and referral for behavioral health care • Delegation of UM

46. Utilization Management Models of Care • Not unique to UM. • Potential to change the UM practices of providers, patients, payers and other stakeholders of health care • Prominent models being used: • Chronic care Model • Evidence-Based Medicine and Evidence-Based Management Model • Patient-Centered Medical Home

47. Utilization Management Chronic Care Model • Models of care for people with any condition that requires ongoing self-management and interaction with the health care system. • Can be applied to systems and patient across various chronic illnesses. • Systems that use this form of care delivery can range from large multihospital health care organizations to single practitioner practices. • The elements of the CCM include the following • Self-management support • Health System • Delivery System Design • Decision Support • Clinical Information Systems • The Community

48. Utilization Management Self-Management Support • Empowers and prepares patients to manage their health and health care. • Emphasizes patients’ central role in managing their health using effective self-management, support strategies that include goal setting, action planning, problem solving and follow-up. Health System • Helps to create the culture, organization, and mechanisms that promote safe, high-quality care through open encouragement and systematic handling of errors and quality concerns to improve care.

49. Utilization Management Delivery System Design • Aims to assure delivery of effective, efficient clinical care and self-management support through defining roles for each health care team member, and distributing tasks among team members who follow patients on a regular basis. Decision Support • Promotes clinical care that is consistent with scientific evidence and patient preferences. • Patient should receive information about evidence-based guidelines to encourage their participation.

50. Utilization Management Clinical Information Systems • Aims to organize patients and population data to facilitate efficient and effective care: • Timely reminders for physicians and patients • Identify relevant sub-populations for proactive care • Facilitate individual patient care planning and monitoring • Share information with patients and providers to coordinate care • Continuously monitor the performance of the practice team and the care system.