Medical Management Shifts Focus to High-Risk Patients, URAC Study Finds

A major URAC study finds that medical management companies are using their resources to identify and manage patients who are most likely to incur high-cost care and spend less time on routine care review than in the past.

The finding is one of several detailed in Trends and Practices in Medical Management, URACís 2005 profile of the medical management industry. Medical management refers to a broad array of practices, such as utilization management, case management and disease management, which are used to provide oversight to the practice of medicine. The report is based on survey results from 282 medical management companies, along with insights gleaned from telephone interviews and focus groups.

The entire report is available at no charge from URAC in an online format at www.urac.org

URAC is a national leader in medical management quality through its accreditation of hundreds of health plans and medical management organizations, educational programs, research and reports.

Research into the industry keeps URAC on top of best practices as we promote health care quality through accreditation and other programs, said Alan P. Spielman, president and CEO of URAC. Our unique approach to accreditation offers companies the flexibility to demonstrate how their organizations meet recognized quality standards across the many modes of medical management.

Enhanced medical information technology with applications for predictive modeling, and identification of high risk members has helped medical management companies to prioritize consumer contact, the report finds. The move towards care coordination and more targeted interventions has resulted in new strategies which allow closer monitoring and guiding of patient care. Many companies include among their practices on-site reviews at hospitals and provider facilities, face-to-face meetings with patients, proactive telephoning, and even home visits.

That has implications for how medical management companies operate across the board, Spielman said. It may mean case managers and disease managers have fewer patients, but each patient may have more complicated needs.

National trends detailed in the report reveal a medical management industry in a dynamic period of transition. Its core utilization management and case management activities remain viable and valuable, and disease management is growing rapidly. The drive towards a national health information exchange network will no doubt accelerate the technological transformation already underway within the industry.

Interestingly, we found that technology has not replaced the one-to-one personal contact that adds value in some medical management areas, particularly in case management, Spielman said. Most of those we surveyed agreed that there are expanding opportunities for medical management in the years ahead, particularly in the areas of consumer-directed health care, electronic utilization management and predictive modeling.

The survey also found that URAC-accredited medical management companies are more likely to measure and report quality performance and use evidence- based guidelines than non-accredited companies. The finding reveals that accreditation is directly linked to a companyís likelihood to promote industry best practices.

That confirms what many purchasers have known intuitively for years: a medical management company that is accredited is more likely to be transparent in its operations, said Neil Trautwein, assistant vice president of human resources policy for the National Association of Manufacturers, the nationís largest industrial trade association, and a URAC board member. The survey also found that companies with URAC accreditation in particular measure more and produce more quality reports that companies with other accreditations.

Other key findings include:

- Greater customization: Medical management companies are now using a more customized approach to the specific needs of clients as they upgrade and integrate their technology platforms and expand their scope.

- Use of medical review criteria: Most companies in the industry rely on a small number of commercial sources for medical review criteria, and often construct their own criteria by combining sources and filling in gaps.

- A growing market: Most see expanding opportunities for medical management in the years ahead, particularly in the areas of telephonic case management, consumer-directed health care, electronic utilization management and predictive modeling.

Distributed by HR Marketer.com