Reference this article to find identification criteria for utilization management.
Categories include:
- Metabolic Syndrome and Pre-Diabetes Risk
- Utilization Management – Emergency Room
- Utilization Management – High Utilization
- Utilization Management - Hospitalization
- Medication Therapy Management (MTM)
Metabolic Syndrome and Pre-Diabetes Risk
Metabolic Syndrome is a combination of medical disorders (Hypertension, Dyslipidemia and Obesity) that, when present, increase the risk of Cardiovascular Disease and Diabetes. This dashboard provides a method to identify patients with evidence of Hypertension and Disorders of Lipid Metabolism based on the condition markers, as well as evidence of Obesity either through the presence of a medical diagnosis (EDC NUT03) or a weight control medication (Rx-MG ENDx070), but with no evidence of Diabetes already being present. This is a group of patients that may benefit from targeted, pro-active interventions aimed at preventing, or at a minimum, delaying the onset of more serious medical conditions.
This group of patients may warrant further assessment of lifestyle choices, but may also benefit from a review of medications being taken to control their Hypertension and high cholesterol, and whether they are adherent with filling those prescriptions.
Utilization Management – Emergency Room
The criteria used on this dashboard identifies patients who have no evidence of seeing a provider on an ambulatory basis (and hence, also no generalist involved in their care), but who have multiple ER visits (greater than two). The criteria are further refined by excluding patients with EDCs that are frequently, and appropriately associated with ER visits. The following EDCs are excluded:
- EYE10 (Foreign body in eye)
- EYE12 (Traumatic injuries of eye)
- FRE04 (Pregnancy and delivery with complications)
- GSU12 (Burns--1st degree)
- REC02 (Lacerations)
- TOX02 (Adverse effects of medicinal agents)
- MUS04 (Fractures, excluding digits)
Of primary concern are patients that do not have any follow-up ambulatory visits and therefore, probably are not receiving any ongoing management and education about their conditions.
Utilization Management – High Utilization
The ACG Coordination markers (Unique Provider Count, Specialty Count, Majority Source of Care and Generalist Seen) can be used together to provide a comprehensive picture of coordination of care. The ACG System assigns patients into three levels indicating the risk for coordination issues: Likely Coordination Issue (LCI), Possible Coordination Issue (PCI), and Unlikely Coordination Issue (UCI). A high unique provider count tends to be the major risk factor for potential coordination issues.
To identify patients that are at risk for future high utilization, it is reasonable to assess the Coordination Risk in conjunction with previous utilization. Two utilization markers to consider are the Unplanned Inpatient Hospitalizations count and the Readmissions 30 Day count. The Unplanned Inpatient Hospitalizations count is a subset of the inpatient hospitalizations count with exclusions for planned admissions.
A planned admission is defined as either a definitively planned procedure, such as rehabilitation services, chemotherapy and transplants or a potentially planned procedure, such as hip replacements, cardiovascular procedures and other inpatient surgical treatments without evidence of acute complications such as infections, burns or injuries. Any inpatient hospitalization that cannot be identified as definitively or potentially planned is considered unplanned. The Readmissions 30 Day count is a subset of the All Cause Inpatient Hospitalizations count. The presence of this count indicates, regardless of cause, the identified admission occurred within 30 days of a previous admission.
Utilization Management - Hospitalization
Hospital Dominant Morbidity Types represent a small subset of diagnoses associated with high rates of admission in the following 12 months. The Hospital Dominant Morbidity Types contribute significantly to the ACG System cost predictions. They have high Positive Predictive Value (PPV) but lack sensitivity in identifying the full pool of patients at risk for hospitalization. The Hospitalization Prediction models use hospital dominant morbidity types in addition to ACG-defined co-morbidity and previous utilization to identify risk of hospitalization across the entire population.
The criteria used on this dashboard identifies patients with a high likelihood of hospitalization within the next 12 months, who do not have evidence of active cancer treatment and are not receiving dialysis. Patients are identified with prior costs below the 95th percentile, which indicates patients that may not already be included in a care management program.
Medication Therapy Management (MTM)
Medication Therapy Management (MTM) programs are designed to improve medication adherence, patient safety and quality. The programs typically focus on promoting beneficiary education and counseling, increasing enrollee adherence to prescription medication regimens and of detecting adverse drug events and patterns of over-use and under-use of prescription drugs. These outreach programs should target individuals with multiple chronic conditions, such as, but not limited to, diabetes, asthma, hypertension, disorders of lipid metabolism, and congestive heart failure, who are taking multiple covered Part D Drugs and who are identified as likely to incur annual costs above a specified
threshold. The ACG System pharmacy-based predictive models and the Rx-MG classifications provide an excellent means of finding the population of individuals eligible for these programs.
The U.S. Centers for Medicare & Medicaid Services (CMS) guidelines provide healthcare organizations some flexibility in determining the eligibility criteria for their MTM programs and the ACG System can support various selected methods. For a full explanation of the MTM program criteria, refer to the CMS guidelines at www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/MTM.html
The identification criteria used here identifies members with at least three chronic conditions (based on medical claims), taking at least eight unique drugs, with current pharmacy costs of at least $3,017.