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Network Medical Management
Network Medical Management

Rick Krohn
As a health care enterprise, the physician led network distinguishes itself through the combined reputation of its membership. But as a business enterprise, the physician led network must capture market share by distinguishing itself from the competition, by competing on terms of price, or quality, or both. And as managed care markets mature, and the competitive advantages gained by productivity gains and cost compression cease to repeat themselves, the market gravitates towards quality as a primary driver. The network must be positioned to meet this market demand, by demonstrating the ability to manage risk, manage utilization and outcomes, and deliver quality across the continuum of services. A key product of the network information system is clinical information, which is the backbone of network medical management programs. Clinical information in turn comprises the source material for network medical management programs. Medical management is an umbrella term which captures a variety of quality and productivity related functions, ranging from referral management to population based care management. The guiding principles of all medical management programs are quality and clinical efficiency. The phrase "provide appropriate care, at the appropriate time, in the appropriate setting", probably best captures the conceptual framework of medical management, particularly in a risk contracting environment. The correct interpretation of the term "appropriate" has been and promises to re-main a divisive issue of quality care. It is the challenge of the network medical director(s) and the medical management committee to define the parameters of quality care and clinical efficiency, and to construct medical management tools and programs to support these expectations. These tools range from practice guidelines, clinical pathways, caremaps, and outcomes measures to formally defined demand and disease management programs.

The key conceptual framework of medical management is care management, which describes a transformation from traditional, fee for service based treatment of illness to a more proactive process of managing health. Care management requires a reengineering of health care delivery, by intervening earlier in the health cycle, coordinating the resources of care delivery, empowering and educating the patient about their health, introducing innovative care delivery modalities, managing the health of patient populations, and using information as a clinical decision making tool.

Clinical Resource Management
Cost pressures are forcing providers to reexamine and reengineer the clinical resources expended in the delivery of care. This redesign of the care process is intended to match the service to the appropriate skill level and to create ongoing efficiencies. The role of patients, non physician providers, nursing triage personnel, and non physician providers are being expanded to assume responsibilities and functions formally reserved to the physician. Physician extenders (physician assistants and nurse practitioners) have proved to be effective in conducting initial patient intake and patient assessment, as well as immunizations and routine care, and these functional roles free up the physician for more intensive patient care. Studies have shown that physician extenders increase physician capacity by as much as 50%. Clinical resource reallocation addresses a number of organizational priorities: operating efficiency; patient access; and patient satisfaction. These strategies tend to be easier to implement than more complex medical management techniques such as guidelines and are suited to earlier stage medical management initiatives.(1)

In addition to managing the resources of care delivery, medical management incorporates sophisticated information tools that support the network goals of quality and resource efficiency. These clinical tools also promote the emergence of a unified clinical culture throughout the network, in that they reduce the incidence of variation in outcomes, utilization, and productivity.

Guidelines, Protocols, and Pathways
Key components of medical management are clinical decision support tools. Guidelines, protocols and pathways are guides for provider decision making. Guidelines are often primary care based and suited to ambulatory care, clinical protocols are often specialty based and suited to specific disease states, and clinical pathways are often procedurally based and suited to the inpatient setting. Experience has shown that the best implementation strategy of guidelines is to introduce a finite number initially, to keep them simple, and to measure only one or two critical factors relative to the guideline.

These decision support tools may include recommendations for diagnosis, treatment, health maintenance, primary prevention, patient education, and self management. It is important to distill the information and present the key point in an annotated algorithm. Again, simplicity and focused measurement are central themes of the process.

Like guidelines, protocols and pathways are algorithm driven decision support tools that are bounded by specific health conditions and disease states. Based upon clinical data derived from populations of patients with similar health and disease characteristics, and guided by the principle of evidence based care, these tools provide a framework for the treatment of chronic, resource intensive conditions as well as common ailments.

Preventive Health Management
In the wake of managed care and risk contracting, a renewed emphasis has been placed on effecting the overall health of patient populations, prior to the onset of illness. These programs and interventions have proven highly effective (and cost effective). Examples include the following

Preventive care - immunizations, health screenings, prenatal counseling are techniques employed to preempt potential health problems within a defined patient population.

Wellness - on site health clubs, smoking cessation, dietary counseling, and stress management are examples of techniques employed, usually in collaboration with employers, to influence individual lifestyles and introduce an attitude of health observance.

Patient Education - although not new, an expanded effort to educate patients about their health, and their personal responsibility to assure its' continued maintenance, is being bolstered by multimedia educational tools the Internet, books, pamphlets, newsletters, and video. Patients are also being invited to attend formal educational programs, meet informally with physicians to discuss health issues, and access telephone based health information libraries.

Demand Management
Particularly in risk based networks, an primary goal is to efficiently coordinate the ongoing care requirements of patient populations. Demand management is a core strategy of this effort, in keeping with the principle of " appropriate, care, at the appropriate time, at the appropriate location". As it happens, appropriate care often occurs outside the physician office, and often does not require physician intervention. The following demand management techniques illustrate this point.

Call Centers - Inbound telephone service representatives (including nurse and counselors) can assist in for provider selection, appointment scheduling, patient screening, and algorithm driven health appraisals, as well as coordination of care and case management functions. Outbound telephone service representatives can perform telephone reminders for medications and medical appointments. Telephone counselors can also monitor the health status of patients with chronic conditions and conduct a baseline assessment of effectiveness for health treatments and medications. Call centers can address a wide range of patient needs, including triage, pregnancy, lifestyle issues, medical procedures, disease management, case management, medication compliance, physician referral, resource referral, care referral, emergency response, and poison control.

Nurse Triage - Nurse counseling is a favored service among health care consumers, because it provides instant access to qualified medical advice and streamlines the process of addressing health problems by identifying the right care modality and course of treatment. Toll free "Ask-A-Nurse" programs have proven to be highly effective in managing patient care, reducing visits, and have produced savings in excess of $3 for each $1 invested in the program.

Self Care - actively involving patients in their own health maintenance has proven successful in reducing admissions and improving outcomes. Patients are educated about their conditions and the actions they can take, without provider intervention, to maintain or improve their condition. This may include physical therapy, lifestyle adjustments, and drug therapy.

Home Care - almost without exception patients prefer to be treated in their own surroundings, and home care professionals provide a lower cost, high quality alternative to inpatient care. This is useful for rehabilitation, chronic illness, dialysis, and other therapies. Home assessments also contribute to the goal of achieving a supportive health maintenance environment.

Disease Management
Disease management has been described as "a clinical management process of care that spans the continuum of care from primary prevention to on-going and long health maintenance for ind-viduals with chronic health conditions or diagnoses".(2) Disease state management is becoming increasingly common as a technique of managing a defined disease condition proactively and providing a course of treatment that intervenes earlier and encourages care delivery in ambulatory settings. Disease management programs are designed to address specific conditions, and incorporate guidelines, drug therapy, care team coordination, and data analysis. Not surprisingly, the focus of disease management programs has gravitated towards high incidence/high resource utilization disease states, such as asthma, diabetes, congestive heart failure, hypertension, and cancer. Consistent with the aggregate consumption of health care resources, and as the U.S. population continues to age, the breadth of such programs will grow to accommodate large scale Medicare populations.

In conjunction with sophisticated information technology that provides evidence based data and resource management, disease management programs blend the best information with the best decision support mechanisms, with the optimal clinical configuration of providers to deliver care, to determine the best course of treatment

Outcomes Measurement
The fullest flowering of the medical management concept is the idea that clinical tools can be applied to improve quality and efficiency across the continuum of health care, and that these improvements can be validated by improved health outcomes of entire patient populations. Consistent with this belief, it is felt that health care is gravitating from care management to outcomes management. The difference, it is argued, is that care management techniques have been incident based and concentrate on existing conditions while outcomes management seeks to create a better result at an earlier stage of the disease or condition. This is accomplished by measuring the effectiveness of care from three distinct perspectives: measurement for accountability; measurement for improvement, and population health measurement.

Measurement for Accountability
This is a performance measure used to demonstrate quality to external parties. A commonly used measurement device is the HEDIS report card used to demonstrate health plan quality to purchasers and consumers. Measurement criteria ranges from utilization and quality indicators to referral patterns and patient satisfaction.

Measurement for Improvement
These measures are an internal device intended to improve quality by effecting provider behavior. Techniques include performance measurement, process analysis, and benchmarking. It is in support of measurable clinical quality improvement that protocols, guidelines, pathways, disease management, and other medical management programs are implemented.

Population Health Measurement
This is an effort to identify highrisk/high utilization populations, and then define course of treatment to improve the overall health of those populations. For instance, outcomes for patients at risk for cardiac disease respond favorably, as a group, to preventive interventions aimed at life-style changes including nutrition, smoking cessation, and exercise.

The cornerstone of the outcomes based care is continuous quality improvement, not saving money. The process and techniques of care are continually examined to identify incremental improvements that translate into improved outcomes. (3)

Implementing the Program

The Network Medical Director
The Medical Director is the chief architect of network medical management programs, and in this capacity must be conversant with both the operational as well as clinical aspects of care delivery. The role of the network Medical Director differs from its' traditional physician/administration interface focus in that the scope of responsibilities includes development of the medical management function. The Medical Director is expected to be not only a strong physician leader, but a business savvy manager capable of merging the clinical and economic objectives of the network. The medical management development process is a key accountability of the medical with network administrative and operational staff accountable to the medical director for implementing medical management programs. The medical director brings a physician sensibility to the development of analytical and decision support tools based on statistical indicators. This is necessary to lend credibility to the output of the system, and generate physician support of improvement efforts based on the prevailing statistical evidence. In addition to technical skills, the medical director should possess solid business management and communication skills, since he/she will be responsible for equating clinical excellence with clinical efficiency in accordance with overarching network goals.

Functionality and Acquisition
Like the information system selection process, developing a network medical management capability proceeds from a series of strategic decisions. First, the Medical Management Committee, working in collaboration with the network Medical Director(s), must determine the functionality of the medical management program. Is it intended to support network quality and productivity goals, or will it also be a key risk management and brand marketing tool? Second, once the functionality has been determined, how can this capability most efficiently be obtained - build, buy, or lease? Third, what are the infrastructure requirements, including human resources, of maintaining this capability? Fourth, how will the network educate and otherwise motivate network physicians to adopt medical management tools and techniques? The answers to these questions are a function of local market dynamics, the quality proposition of the network, network clinical resources, and capital limitations. In many cases elements of a network medical management programs may already be operating within participating practices, groups, or alliance partners. The Medical Management Committee may wish to conduct as part of its' due diligence an analysis of "best of breed" products among network participants. For example, a practice or group may have independently developed a demand management program based on telephone triage, physician extenders, or patient education. Another example might be a larger entity (such as a large group or hospital alliance partner) that may have developed protocols or outcomes measures, which can be rolled out by the network to its' entire membership. For organizations with little established medical management infrastructure, it is likely that this capability will be obtained externally. There are a wealth of ready sources of medical management tools and data, and the Medical Management Committee must conduct an exercise not unlike the information system selection process to identify the optimal product which not only meets the specifications of the medical management program, but can be successfully implemented within the operational limitations of the network information platform. The Internet presents a flexible (and cost effective) method of connecting the various data sources and locations within a scalable platform. This strategy holds great attraction from several perspectives: cost and maintenance, access, and ease of use.

Because the development issues of each discipline are so intertwined, the Medical Management Committee must work closely with the network information systems staff to achieve the optimal mix of functionality, accessibility, and operating efficiency. Clinical representation on the Information Systems Committee, and Information system representation on the Medical Management Committee, are the obvious answer to this overlap in purpose and product.

The correct network medical management strategy is one that meets the quality, productivity, and cost efficiency goals of the organization, subject to capital and operational limitations, and subject to the dynamics of local market contracting and competitive factors. Regardless of the point of departure for the medical management program, its' ultimate aim should be to implement a comprehensive array of strategies designed to cultivate a managed care mentality and a unified network clinical culture. The focus of intervention between provider and patient should shift towards preventive care and the health of patient populations. Innovative techniques such as nurse triage, physician extenders, patient education and self care should be deployed early in the process. More complex strategies such as protocols, guidelines, pathways, and case management should be im-plemented carefully, to allow both clinical and non clinical staff the opportunity to absorb the functional transition. Advanced medical management strategies such as disease management and outcomes measures can only be introduced in the presence of sophisticated information resources, and are more likely to be implemented in risk bearing organizations. Finally, providers must be properly motivated - through profiling and decision support tools - to adopt the medical management techniques that translate into quality and efficiency gains across the entire spectrum of net-work services.

1. Houck, Sue, "The Myth of Managed Care: Moving Beyond Managing Cost to Really Manag-ing Care". Cost and Quality, Studio City, CA, Volume 3, Number 1, 1/97.
2. The Disease Management Strategic Research Study and Resource Guide, National Managed Health Care Congress, 1996, p.7.
3. Rovner, Julie, "Using Outcomes to Improve Care and Measure Success" Risk Management for Health Care Provider Groups 1998, Faulkner and Gray, N.Y., N.Y., 1997, pp.280-291.

Richard Krohn is a member and contributor of HealthBond. View his expert page on HealthBond.

Richard Krohn is President of HealthSense. Krohn is a widely-published managed care expert as well as a dynamic speaker providing in-depth, practical and timely information on topics such as managed care contracting, strategic positioning for provider organizations, building new provider alliances, reengineering practice operations, developing market driven products, and creating equitable physician compensation plans.

November 30, 2000

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