QUIZ 2: UTILIZATION MANAGEMENT: AN EVOLVING APPROACH TO MANAGING CARE

OVERVIEW 10:

UTILIZATION MANAGEMENT PART 2

MANAGING THE UTILIZATION OF HEALTH CARE SERVICES:

POST-2000 APPROACHES TO UTILIZATION MANAGEMENT

HSA 312 SPRING 2021

KEY POINTS AND STUDY GUIDE

WEEK OF APRIL 26, 2021

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TO DO:

· READ COMPLETELY THROUGH THIS OVERVIEW A COUPLE OF TIMES.

· DO THE READINGS BELOW AS INDICATED? ALTOGETHER THEY ARE ABOUT 25 PAGES LONG – MAYBE A BIT LESS.

A. OVERVIEW OF KEY FEATURES OF A COMPREHENSIVE UTILIZATION MANAGEMENT APPROACH IN 2021.

Focus on designing and implementing Utilization Management interventions which are complex and well-coordinated:

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

· Use Large Data Bases: including EHRs (Electronic Health Records) and other insurance plan, hospital, Integrated Delivery System, and public (Medicare, for example) databases.

· Clearly identify defined clinical processes, clinical outcomes, and clinical events as indicated below:

· The importance of these processes, outcomes, and events should be agreed upon by clinicians, health services administrators, insurance plans, and health policy analysts based on a systematic review of relevant data, and based on transparent communication and consensus – building by the parties collecting, using, and evaluating those data.

· Identify clinical events (admissions, discharges, lengths of stay, ambulatory care episodes and visits) which are significant in terms of volume of service, potential overutilization of services, and quality of care, and which can be clearly defined in terms of ICD 10-CM, CPT-4, and other diagnosis and treatment coding systems. In other words, the data concerning these events is clearly coded and retrievable from current information sources.

· Use routine collection, review, and analysis of selected processes, outcomes, and events to determine variations from expected and accepted clinical norms of experience and behavior.

· Use information on the routinely monitored data and variations to focus Utilization Review and other Utilization Management efforts and to ensure that Utilization Management is efficiently done, quality-oriented, and effective in terms of focusing of significant clinical quality and utilization issues.

2. Give high priority to issues of Clinical Coordination of Care, and to implement targeted programs which expand the use of that Coordination to improve patient outcomes, and to prevent future unnecessary utilization or inappropriate utilization of clinical services.

( For example: Support use of Medical Homes ; insurance plans should be making effective and proactive use of Disease Management. )

3. Give high priority to the critical role of Social Determinants of Health in facilitating the effectiveness of clinical care. Implement programs that jointly address appropriate clinical care, and the resolution of a patient’s social issues to support truly effective clinical treatment and better patient outcomes.

4. 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.

5. Encourage the use of both more traditional, and more innovative forms of, Demand Management: Focus not just on Preventive Care, Wellness Programs, Nutrition Programs, and Programs oriented toward exercise and other forms of individual and family Self-Care, but also on Patient-Centered Care in which patients are more actively involved in discussing and understanding clinical decisions as part of their routine interaction with clinical providers, such as physicians. ( For example: Patient Decision – sharing.)

B. POPULATION HEALTH AND BIG DATA: ADDRESSING AND GOING BEYOND THE TRADITIONAL FOCUS OF UTILIZATION REVIEW ON ACUTE CARE.

READINGS 2.A. AND 2. B.

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.

2. The Focus of Big Data analysis is Prospective for defined patient populations (Health Plan Enrollees, Hospital or Health Care System Routine Patient Populations) – it is not just driven by the immediate acute medical problems of Health Plan Enrollees or the Patient Population, but also by the clinical characteristics identified whether or not the members of a given population are currently accessing health care services.

3. UTILIZATION REVIEW: Traditional utilization review continues, as described above, but with an expanded, more systematic and data-based focus AS INDICATED IN A.2.ABOVE.

· Choice of Subjects for Utilization Review: Now chosen through a much more systematic, structured, data-driven, open and transparent process of analysis and discussion.

Before 2000, Utilization Review was often based on whether or not a particular patient population

(members of a group health plan; a community routinely using a particular hospital or Integrated Delivery System of health care providers.) had utilization patterns considered normal for that group or community. ( SEE READING 1.1 FOR THE KINDS OF DATA THAT HEALTH INSURANCE PLANS USED TO GUIDE THEIR UTILIZATION REVIEW EFFORTS PRIOR TO 2000).

· Utilization Review increasingly uses specific indicators of overutilization or other utilization problems which are tied to clearly defined and specified clinical conditions. SEE EXAMPLES BELOW – SEE READINGS 4.1 THROUGH 4.5 FOR THE WEEK OF APRIL 19.

The prevalence and incidence of these problems can be determined through computer analysis of large clinical and billing databases maintained by Health Insurance Plans and Integrated Delivery Systems.

· Ambulatory Sensitive Conditions and related Potentially Avoidable Hospitalizations.

· Hospital Acquired Conditions – also known as Potentially Preventable Complications.

· Hospital Readmissions within 30 Days of Discharge – For specified clinical conditions, identified by Diagnosis Related Group. ( For Example: Acute Myocardial Infarction (AMI); Chronic Obstructive Pulmonary Disease (COPD)

· Never Events – As defined by Medicare.

C. UTILIZATION MANAGEMENT – IDENTIFYING CURRENT OR POTENTIAL HIGH UTILIZERS OF HEALTH CARE SERVICES:

READINGS 3.A. AND 3.C. – ALL. ALSO 4.B.

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:

· For instance, identifying trends in Emergency Room utilization, and implementing programs to reduce unnecessary ER usage.

· Implementation of Hot spotting Programs - See the experience of the Camden Hot spotting program.

· 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)

D .ENCOURAGING THE EFFECTIVE USE OF COORDINATED CARE FOR PEOPLE WITH CHRONIC CONDITIONS – IMPLEMENTING DISEASE MANAGEMENT.

READINGS 5.A. AND 5.B.

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

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

2. Making those packages of services available in advance (before the individual’s clinical situation seriously deteriorates) in order 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.

E. ENCOURAGING THE EFFECTIVE USE OF COORDINATED CARE FOR PEOPLE WITH CHRONIC CONDITIONS – IMPROVING COORDINATION OF CARE THROUGH MEDICAID HEALTH HOMES.

READINGS 6.A. AND 6.B.

FOR MEDICAID RECIPIENTS: Identify Coordination of Care issues , and facilitate more extensive and effective quality coordination of care among providers and across care settings (hospitals, rehab facilities, the patient’s home, Primary Care Physician offices):

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

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

F. IDENTIFYING, UNDERSTANDING AND ADDRESSING THE IMPACT OF SOCIAL DETERMINANTS OF HEALTH. READING 4.B.

1. Identify the impact of Social Determinants on the prospects for higher level health status and successful treatment.

2. Implement programs to address those issues, and to incorporate resolution of those issues into the total treatment plan and the set of clinical interventions for the patient.

3. 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.

G. DEMAND MANAGEMENT INCLUDING THE CONCEPT OF PATIENT DECISION-SHARING IN MEDICAL TREATMENT DECISIONS.

READING 8 on Patient Decision-Sharing.

1. TWO SETS OF APPROACHED TO DEMAND MANAGEMENT:

Demand management is the process of empowering patients to make wiser health care decisions.

It is not necessarily about reducing demand for personal health care services though that may result from the two types of Demand Management outlined below.

· FIRST: One goal of Demand Management is to reduce the need for health care goods and services by improving patients' health status. The emphasis here is on wellness, health promotion, risk reduction, prevention, screening and early detection for individual patients and their families. The goal is to engage patients in the quest for better self-care, better personal health status, and appropriate care as necessary. If that reduces the level of health care service demand, that is a desirable by-product of those activities.

THIS IS THE TRADITIONAL DEMAND MANAGEMENT APPROACH, WHICH PREDOMINATED PRIOR TO 2000, AND IS STILL THE CENTRAL PART OF DEMAND MANAGEMENT IN MANY HEALTH INSURANCE PLANS.

· SECOND: Since 2000 an additional component of Demand Management in some health insurance plans is the implementation of patient-centered Shared Decision-making programs which respect and address patient treatment preferences. (Preference Sensitive conditions.)

This Demand Management strategy attempts to improve patients' decisions about medical treatment for a selected group of medical conditions. Tools such as patient education materials, telephone advice lines, and consultation with specially trained Nurse Consultants can aid the decision-making process by making patients more informed and assertive in their interactions with Physicians. SEE 2. BELOW FOR MORE DETAIL.

2. The implementation of patient-centered Shared Decision-making programs . One of the most discussed aspects of this Demand Management strategy is the greater involvement of patients in decisions about the appropriate treatment for selected high-volume procedures (Patient Decision Sharing).

· Note: Not all medical interventions are appropriate candidates for the kind of intense patient involvement entailed in Patient Decision-Sharing.

· Treatments and Hospital Admissions associated with Preference Sensitive Care are the medical interventions most likely to be the subject of Patient Decision Sharing.

· Preference-sensitive care comprises treatments for conditions where MULTIPLE legitimate treatment options exist: There is more than one treatment option. Choosing among multiple treatment options involves making decisions about significant tradeoffs among different possible outcomes of each treatment. (For example, some people will prefer to accept a small risk of death to improve their function; others won’t).

Examples: Treatment of prostate cancer; treatment of certain types of chronic lower back pain.

· Extensive research by the Dartmouth Atlas of Health has shown that there are major variations by region of the United States in which treatments are given for such conditions. Specifically, after adjusting for patient age, sex, severity of medical condition, and other factors, researchers discovered provider treatment preferences or biases which may indicate that patients do not fully understand the full range of treatment options for a given condition, and may not have a good understanding of the trade-offs involved in choosing one treatment over another.

There is some evidence, though not conclusive, that Patient Decision Sharing in decisions about Preference-sensitive Care can lead to better patient satisfaction and less per capita expenditure without compromising quality of care.

There are several reasons why implementation of targeted Patient Decision Sharing programs by Health Plans, IDS, and single Hospital’s merit consideration as viable tools of Utilization Management.

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