What is Medical Management

Over the past several years, premium increases in many markets have provided Health Plans with enough revenue to operate profitably even if appropriate medical management programs were not in place.
This has changed with many health plans , insurance companies and third party risk managers such as IDNs failing.
In fact the leading cause of death among most health plans has been medical expense ratios that represent losses in excess of premium due to a poor understanding of how to design and implement a meaningful medical management program.

The PHDC approach to medical management involves implementing a comprehensive strategy that co-ordinates utilization and quality management activities with contracting, claims payment, operational efficiency, marketing, finance and underwriting. Within PHDC we therefore have the resources to create meaningful change to transform the delivery system and monitor improvements translating them to a competitive marketing advantages rather than merely pursuing medical management as an accounting or academic discipline isolated from overall organizational policy and decision-making.

By focusing the entire organization on key cost levers, it becomes possible to make meaningful improvements in medical costs.
For example, our experience in reducing hospital bed-day use is based on simple and reproducible activities such as setting clear targets, benchmarking performance, identifying outlier areas, and then working with physicians to improve patterns of care.

Specific strategies that we have implemented successfully in many locations include:
• Improving access for patients to primary care or urgent care to reduce emergency room visits and costs;
• Directing care to centers of excellence for high cost and high risk procedures such as cardiac surgery and neurosurgery to improve quality outcomes and costs;
• Building strong links to nursing homes, home health, home infusion, and hospice to avoid unnecessarily prolonged hospital stays;
• Developing disease management programs that focus on patient education and physician support;
• Managing levels of care within the hospital, not just length of stay;
• Building strong physician relationships to reduce their hassles and to support our initiatives;
• Identifying and implementing improvements by clinical specialty using evidence-based guidelines;
• Directing care to preferred providers based on quality and cost;
• Addressing physician performance issues through one-on-one coaching and network reshaping, if necessary;
• Focusing the utilization management staff on activities that improve quality and reduce costs rather than on processes that add little value;
The benefit of our work with transforming delivery system is building a medical management team that understands how to solve problems. This gives the community input and influence over the definitions of quality and allows progress and potential to be measured locally.