FINAL EXAMINATION - DUE: 11:59 PM, MAY 24 HSA 312 - 01: MANAGED HEALTH CARE · PAYING PROVIDERS. · UTILIZATION MANAGEMENT ¨ ¨ ¨ ¨ ¨ QUESTIONS TO BE ANSWERED A

OVERVIEW 1 - SUMMARY:

MORE RECENT UTILIZATION MANAGEMENT STRATEGIES

1. Using Big Data, analyzed with the assistance of high-speed computers, to identify the incidence of and trends in clinical characteristics of plan enrollees (for Health Insurance Plans) or routine patient populations (Hospitals and Vertically Integrated Delivery Systems). Also to be analyzed: trends in treatment, diagnosis, pharmaceutical utilization.

1. Focus of Big Data analysis is Prospective for defined patient populations (Health Plan Enrollees, Hospital or IDS Routine Patient Populations) – The focus of Utilization Management is not determined by the immediate acute medical problems of Enrollees or the Patient Population, but by clinical characteristics of and trends for defined populations, whether or not the members of a given population are currently accessing health care services.

1. Focus on identifying high priority Utilization Management targets (Frequent Flyers, High Utilizers) using population-based data, and implementing programs to influence the utilization of health services by the targets.

FOR EXAMPLE:

• Identifying and working with actual or potential high utilizers:

• Identifying trends in Emergency Room utilization, and implementing programs to reduce unnecessary ER usage;

• Implementation of Hotspotting Programs.

• Following trends in potentially avoidable hospital admissions and using targeted programs to change those trends: For instance, see the Medicare Hospital Readmissions Reduction Program (HRRP). The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions:

The program supports the national goal of improving healthcare for Americans by linking payment to the quality of hospital care for Medicare patients in the following clinical groupings who are potentially at risk for readmission to a hospital within 30 days of an initial hospital stay.

• Acute Myocardial Infarction (AMI)

• Chronic Obstructive Pulmonary Disease (COPD)

• Heart Failure (HF)

• Pneumonia

• Coronary Artery Bypass Graft (CABG) Surgery

• Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA/TKA)

1. Focus on prospectively identifying potential needs of a critical subset of the population of interest (Enrollees of Health Plans or Routine Patients of Hospitals or Integrated Delivery Systems):

• Developing packages of coordinated clinical and social services to address those needs; and

• Making those packages available in advance to reduce the incidence or intensity of acute episodes, or (in the case of those with multiple chronic conditions) slowing disease progression and maximizing Enrollee or Patient quality of life, comfort, and functionality in activities of daily living, thus reducing likelihood of high intensity service utilization.

• For example: Disease Management programs.

1. Identify Coordination of Care issues, and facilitate more extensive and better-quality coordination of care among providers and across care settings (hospitals, rehab facilities, the patient’s home, Primary Care Physician offices):

• Maximize appropriate enrollment in and use of Medicaid Health Homes.

• Maximize coordination of services for clinical categories of Patients who are the object of the Medicare Hospital Readmissions Reduction Program (HRRP).

1. Identify the impact of Social Determinants on the prospects for high health status and successful treatment, and; Implement programs to address those issues, and to incorporate resolution of those issues into the total treatment plan and set of clinical interventions for the patient.

• See the experience of the Camden Hotspotting program.

• See the plans for addressing the problems of patients who are the main concern of the Medicare Hospital Readmissions Reduction Program (HRRP) – Notably in the Mt. Sinai Health System PACT Program.

1. Expand and support Demand Management activities, including:

• Wellness programs.

• Prevention and Screening programs.

• The implementation of patient-centered Shared Decision-making programs which respect and address patient treatment preferences. (Preference Sensitive conditions.)

1. Focus on designing and implementing UM interventions which are complex, mixed, and well-coordinated, and which do not rely solely on telephone interventions and the monitoring and activities of centralized Utilization Management staff:

• Use Big Data Analysis, as appropriate, to guide and monitor the effectiveness of interventions.

• As appropriate, combine telephonic and electronic contact with providers and Enrollees or Patients with direct contact with and support for patients: For example - Use Nurses and other health professionals, either on staff or subcontracted through other organizations, to visit and monitor Enrollees/Patients, to ensure that medications are being taken as appropriate, etc.

• As appropriate, and indicated above, address Social Determinants and Coordination issues as critical parts of any Utilization Management intervention