The National Committee on Quality Assurance (NCQA) has advanced the accreditation process for managed care organizations across the nation. Assessing the credentialing, quality management and utilization review functions has been part of NCQA standards since its inception. As the standards have evolved, the number of MCO functions to be considered in the accreditation process has increased and expanded. And this accreditation is becoming a necessity for an MCO to remain competitive in those markets where other MCO's are already accredited.

The presence of NCQA standards in the market place has had a trickle-down effect on those physician organizations which contract with managed care organizations. NCQA details the manner, scope and degree with which MCO's relate to their contracted providers: The standards require the development of partnerships to monitor and oversee physician performance, including credentialing, and quality and utilization management. In fact, the importance of the physician role in maintaining the MCO's accreditation is underscored by NCQA's initiation of an accrediting process for physician organizations.

As MCO's have matured, trends have developed which have had an impact on medical management:

• Physician organizations have expanded the risk they will accept, from primary care alone to full professional capitation.
• MCO's have increased their expertise in the management of more complicated cases, such as organ transplants and rehabilitation, and are focusing their own medical management on the more complex, leaving physician groups to assist with the management and monitoring of more common services.
• HEDIS¹ measures have encouraged physician organizations to assess the use of preventive services and develop strategies to increase that use.

The impact of these changes are as follows:

• The adoption of expanded risk by providers has required them to develop systems and processes to manage utilization of those services for which they are at risk. Additionally, MCO's have encouraged physician organizations to enhance quality management activities by providing financial incentives for selected quality activities.
• As MCO's have focused their attention on the high-cost rare events, physician organizations have responded by developing their own medical management.
• The emphasis on preventive care will, over time, lower the risk for selected patient populations, and decrease the secondary effects of disease.

A well-developed medical management program must be both administratively efficient and clinically sound, as well as relevant to the physician and patient populations being served. The program's policies and procedures guide and support the physician in making clinical decisions. Thus, physicians must be encouraged to participate in their development and ongoing improvement.

Medical management programs promote satisfaction through the provision of tools to assist members in staying well, optimal management of chronic conditions, and provision of support and service coordination during times of acute crisis. For example, one such tool is a case manager who explains the course of treatment, assesses benefits to optimize coverage, coordinates multiple care providers, and is available to answer questions that arise as members move through levels of care is appreciated by those who require it.

Medical management program outcome data can assist other areas in their performance. In an MCO utilization data forms the basis for underwriting, rate setting, determining incentive payment, or withholding returns. In a physician organization such data is used to determine adequate capitation and target areas for improvement. Quality management outcomes support credentialing and incentive payment decisions for both types of organizations.

MCO medical management programs seek to identify at-risk patients, and then reduce that risk and promote appropriate access to care.

• Health risk appraisals. They are conducted with the MCO to identify new members who require intervention to stay well, or who may need assistance coordinating their care as it is assumed by network providers.
• Clinical guidelines and protocols. These are developed to provide support for optimum treatment, including options for medical treatment, patient education, and self care.
• Outreach programs. In cases where members are not receiving appropriate levels of preventive care, outreach programs must be developed.

Case-by-case review is conducted to assess the medical necessity of a proposed procedure or service. Effective resource use is enhanced through the following types of activities:

• Focused Outpatient Pre-certification. As more services move to an outpatient setting, there is an increased necessity to efficiently control outpatient utilization. Pre-certification requires the use of clinical criteria to determine the medical necessity of a proposed procedure and its proposed outpatient setting.
• Referral Management. Referral management processes are changing. Some physician or managed care organizations review all PCP referrals. Others advocate direct member access to specialty providers. The option chosen depends on network organization, referral volume by specialty and specialist, and reimbursement mechanisms.
• Facility reviews. All admissions to acute care, skilled nursing and rehabilitation facilities are reviewed to determine the need for admission and continued stay. The review process requires the use of criteria by a nurse to determine if the admission and/or continued stay is medically necessary. Admissions or stays that fail to meet established criteria are reviewed by a physician for medical necessity.
• Case Management/Discharge Planning. During the pre-certification process, members who need post-facility care are identified. Early identification enables the tailoring of the treatment plan to the patient's needs, assuring adequate patient education and facilitating transition between levels of care.
• Disease Management Guidelines. These provide the tools to identify optimum treatment methods for select conditions, to coordinating the use of health care resources for patients with significant care requirements, for maximum gain.

• Indicator Monitoring. Quality management includes the monitoring of indicators which have been selected based on accreditation/regulatory requirements and organizational priorities. Indicators are typically focused on resource utilization, quality of care, access, and member satisfaction.
• Medical Record Review. Medical record review, using established parameters, can be utilized in peer review or in support of credentialing and re-credentialing activities.
• Medical Evaluation Studies. Performance information from other medical record review or claims data is analyzed to further determine appropriateness of care.
• Patient/Provider Satisfaction Surveys. Surveys are conducted periodically of both patients and providers to determine how the organization can improve its service. Results are forwarded to those responsible for responding to the results.
• Medical Record Review. Reviews with established parameters can be utilized in peer review or in support of credentialing and re-credentialing activities.
• Medical Evaluation Studies. Performance information from other medical record review or claims data is analyzed to further determine appropriateness of care.
• Committee Support. Utilization and quality issues are addressed, solutions identified, and progress monitored through interdepartmental committees, the number and type varying with the complexity of the organization. Medical management staff typically provide the support and information for the committee work.

• Data Analysis and Tracking. This provides a level of understanding about processes and outcomes of care, and provides an understanding of current utilization and cost patterns as they relate to historical patterns or external outcomes.
• Refined Outcome Measures. Through experience and data collection, MCO's and physician organizations can begin to determine what works best for their patient population. Outcomes can be defined in terms of functional status -- the patient's quality of life.
• Provider Profiling. Profiling physicians on costs, utilization and quality indicators assists the organization to determine medical management priorities, including providing feedback to the physician to improve performance.
• Credentialing/Recredentialing. The process should include primary source verification, site visit, and medical record review. Recredentialing verifies information, and reviews such quality outcome measures as utilization performance, and patient satisfaction levels.

• Physicians
• Registered nurses
• Management staff
• Analytical staff
• Clerical staff

• Management information system with a database capable of supporting the review process, including the analysis and reporting of quality and utilization data.
• Telephone system with reporting capability
• Fax transmission capability

• Medical necessity criteria
• Preventive care guidelines
• Disease management guidelines
• Patient and provider satisfaction surveys