MHCM 6310 Strategic Management of Health Services Organizations Key Terms  Utilization management  Quality management  Data warehousing  Validity  Reliability  Provider profiling  Risk adjustment  Pharmacy benefit managers  Drug utilization review programs  Pharmacogenomics  Parity  Density  Credentialing MKT111B 200 Marketing Project – Part 4 Rating Excellent Good Acceptable Developing Unacceptable SCORE Points 180 - 162 161-144 143-126 125-108 107 - 0 Marketing Project – Part 4 Required Elements – must use your chosen company (180 points for this section -Various ethical issues involved in marketing to the consumer were identified -Ways to use CRM tools to provide customer service was discussed -Ways in which value affects the purchasing decision was discussed, used the chosen product/service as an example -Discussed how marketing impacts the buying decisions of customers, organizations, governments, and businesses -Discussed how the total customer experience impacts customer satisfaction -Explained “perception = reality” and looking at things through the customer’s lens -Reflection was well thought out and explained Details of at least one of the required elements to the left are weakly presented or missing Details of at least two-three of the required elements to the left are weakly presented or missing Details of at least four of the required elements to the left are weakly presented or missing Details of at least five of the required elements to the left are weakly presented or missing Rating Excellent Good Acceptable Developing Unacceptable Points 5 4 3 2 0 Writing Mechanics (5 points for this section)sentence structure, run-ons, fragments, agreement, punctuation, capitalization, spelling, etc. Demonstrates knowledge and use of writing mechanics, enhances the readability Demonstrates knowledge and use of writing mechanics with minor errors that do not detract from the readability Demonstrates knowledge and use of writing mechanics but with errors that detract from the readability Difficulties with readability due to inappropriate use of writing mechanics Lacks proper use of writing mechanics – lacks readability Rating Excellent Good Acceptable Developing Unacceptable Points 5 4 3 2 0 Writing Organization (10 points for this section) Coherence: all writing fits together, makes sense, and flows in effective order – beginning, middle, end Clarity: all writing is consistent and logical Coherence: Well organized and purposeful writing; has beginning, middle, and end; strong and appropriate transitions Clarity: Expresses ideas clearly and logically Coherence: Adequate organization; beginning, middle, and end; appropriate transitions Clarity: Expresses most ideas clearly; occasional lapse in logical order Coherence: Sequence of information difficult to follow; lacks a clear beginning, middle, and end; few or inappropriate transitions Clarity: Attempts to express ideas cl ...

1. MHCM 6310 Strategic Management of
Health Services Organizations
Key Terms
MKT111B 200

2. Marketing Project – Part 4
Rating
Excellent
Good
Acceptable
Developing
Unacceptable
SCORE
Points
180 - 162
161-144
143-126
125-108
107 - 0
Marketing Project – Part 4 Required Elements – must use your
chosen company (180 points for this section
-Various ethical issues involved in marketing to the consumer
were identified
-Ways to use CRM tools to provide customer service was
discussed
-Ways in which value affects the purchasing decision was
discussed, used the chosen product/service as an example
-Discussed how marketing impacts the buying decisions of
customers, organizations, governments, and businesses
-Discussed how the total customer experience impacts customer
satisfaction
-Explained “perception = reality” and looking at things through
the customer’s lens
-Reflection was well thought out and explained
Details of at least one of the required elements to the left are
weakly presented or missing
Details of at least two-three of the required elements to the left
are weakly presented or missing

3. Details of at least four of the required elements to the left are
weakly presented or missing
Details of at least five of the required elements to the left are
weakly presented or missing
Rating
Excellent
Good
Acceptable
Developing
Unacceptable
Points
5
4
3
2
0
Writing Mechanics (5 points for this section)sentence structure,
run-ons, fragments, agreement, punctuation, capitalization,
spelling, etc.
Demonstrates knowledge and use of writing mechanics,
enhances the readability
Demonstrates knowledge and use of writing mechanics with
minor errors that do not detract from the readability
Demonstrates knowledge and use of writing mechanics but with
errors that detract from the readability
Difficulties with readability due to inappropriate use of writing
mechanics
Lacks proper use of writing mechanics – lacks readability
Rating
Excellent
Good

4. Acceptable
Developing
Unacceptable
Points
5
4
3
2
0
Writing Organization
(10 points for this section)
Coherence: all writing fits together, makes sense, and flows in
effective order – beginning, middle, end
Clarity: all writing is consistent and logical
Coherence: Well organized and purposeful writing; has
beginning, middle, and end; strong and appropriate transitions
Clarity: Expresses ideas clearly and logically
Coherence: Adequate organization; beginning, middle, and end;
appropriate transitions
Clarity: Expresses most ideas clearly; occasional lapse in
logical order
Coherence: Sequence of information difficult to follow; lacks a
clear beginning, middle, and end; few or inappropriate
transitions
Clarity: Attempts to express ideas clearly; sometimes difficult
to follow
Coherence: Unclear; lacks beginning, middle and end; fails to
use transitions appropriately

5. Clarity: Disjointed connection of ideas; difficult to follow
Coherence: Lacks coherence; beginning, middle, and end, and
transitions
Clarity: Lacks clarity and logic; does not connect ideas
Rating
Excellent
Good
Acceptable
Developing
Unacceptable
Points
5
4
3
2
0
Citations
(5 points for this section
Correctly uses in-text citations for all sources; properly formats
paper and references page
Uses in-text citations with minor errors to identify sources;
paper formatting and or references page displays minor errors
Minor errors or missing in-text citations; paper formatting and
or references page displays minor errors
Frequently missing in-text citations; improperly formats paper
and references page
Lacks in-text citations; lacks proper formatting of paper;
missing or irrelevant references page
Rating
Excellent
Good
Acceptable

6. Developing
Unacceptable
Points
5
4
3
2
0
Critical Thinking (5 points for this section)
Engages with the material; demonstrates insightful ideas from a
thorough examination and understanding of the topic
Balance of source and original ideas shows consistent
interaction with the sources and evidence of critical thinking
Balance of source and original ideas shows inconsistent
interaction with the sources and a decrease in critical thinking
Ideas rely too heavily on sources rather than on critical
thinking; shows minimal interaction between sources and
original ideas
Lacks engagement with the material or lacks evidence of critical
thinking
Instructor Comments:
TOTAL:
Management of Utilization and Quality
WEEK 2 LECTURE
Forces Driving Change In Health Care Delivery
Increased availability of performance data showing poor value

7. Decreased public self-perception of wealth, making provider
choice a luxury
Early experiments showing better performance is possible with
greater system organization
Decreased relevance of geography in purchasing
17% of GDP devoted to health care, a competitive disadvantage
in world markets
Psychological Forces Telling Physicians To Resist Change
Old quid pro quo: financial and social rewards for assuming
responsibility for decision-making with incomplete information
New quid pro quo: national standards, including defined
outcome metrics
Artistry to commodity?
Set up for physicians to resist change and feel morally justified
Behavior Change Tools
Communication
Unidirectional: newsletters, emails, etc.
Bidirectional: Small group meetings
Social media
Analytics: changing data into knowledge
Mission clarity
Programmatic Approaches
Formal CME
Data and feedback
Practice guidelines and clinical protocols
Small group programs

8. Data Analysis: Who Uses the Data?
Employers and their benefits consultants
Government programs
Medicare Advantage (MA) plans
Medicaid managed care plans
State regulators
Medical managers in health plans
Providers
Consumers
The community
Data Sources
Main source is still administrative claims data
New sources beginning to be used include
Lab test results
Biometric information such as blood pressure or body mass
index
Feeds from electronic health records at clinics or hospitals
Patient satisfaction with care received
Operational information on health management programs run by
plans or vendors
Data Warehousing
Minimum Data Elements - Unique patient identifier (scrambled
for patient confidentiality)
Diagnostic information
ICD-9-CM)
ICD-10 beginning October 1, 2013.
Procedural information
Volume III of ICD-9-CM

9. ICD-10
CPT
HCPCS.
Level of service information
Paid dollar amounts from services ordered by the physician or
health care facility
National Provider Identifier (NPI)
Validity and Reliability
Data must be consistent and mean the same thing for all
providers
Challenge for plans running multiple claims systems
Accuracy does not rule out creative coding, coding abuse or
fraud
Provider Profiling
The following principles should be kept in mind:
Identify high-volume and costly clinical areas to profile
Involve appropriate internal and external customers in the
development and implementation of the profile
Involve the providers in the development and implementation of
the profile
Compare results with published performance (external versus
internal norms)
Report performance using a uniform clinical data set
When possible, employ an external data source for independent
validation of the provider’s data
Consider on-site verification of data from the provider’s
information system
Present comparative performance using clinically relevant risk
stratification

10. Require measures of statistical significance for comparisons and
establish thresholds for minimum sample size
Revise performance measurements using formal severity
adjustment instruments
Prescription Drug Benefits in Managed Care
Private Health Plans - Coverage of drugs began with HMOs, but
is now common in most types of plans
Coverage of prescription drugs is usually not part of the basic
medical benefits plan
Technically it’s treated as a rider to the policy
Allows benefits to be altered independently from medical
benefits
Public Programs - All Medicaid programs provide coverage for
drugs, though with some limits
Approximately 90% of Medicare beneficiaries have either Part
D or other credible access to drug coverage
Components of Pharmacy Benefits Management
Two primary approaches
Supply side: managing the cost of drugs
Demand side: managing the rate of drug utilization
Not always about lowering costs
Goal includes appropriate use of drugs and patient compliance
Disease management programs often see drug cost increases,
but more than offset by avoidance of hospital admission
Legally enforceable benefit design contract outlining benefits
Raising patient copayments and coinsurance for prescriptions –
cost sharing
Differential copayments based on tiering
Use of formularies – lists of covered drugs

11. Closed vs. open
Tiered
Increasing the use of generic drugs
Defined pharmacy provider network under contract with the
health plan or PBM. i.e., the Distribution Channel
Components of Pharmacy Benefits Management
Mail order fulfillment
Managing utilization
Drug utilization review – DUR
Step therapy
Use of prior authorization to limit open access to certain
expensive drugs, or drugs with a misuse or abuse potential
Risk sharing with providers by some HMOs
Pharmacy Benefits Managers - PBMs
Company that specializes in managing the pharmacy benefit
May be independent company, contracting with MCO
May be independent company, contracting directly with
employer for a self-funded benefits plan
May be owned by MCO
Autonomous operation
Integrated with MCOs other care management functions
Specialty pharmacy may be managed by a specialty PBM
As part of a traditional PBM
Independent to PBM managing non-specialty pharmacy benefits
Prescription Drug Plans (PDPs) are PBMs that focus on
Medicare Part D drug benefits management
May manage only the drug benefit – PDPs
May be part of a Medicare Advantage plan – MA-PDPs

12. Basic Components of Drug Utilization Management
Step therapy
Drugs may be covered only if step therapy approach is used
Must begin with lowest cost alternatives
“Step” through increasingly expensive alternatives if lower cost
drugs are not sufficiently effective
Usually applied only to very expensive brand name drugs and
most specialty pharmacy drugs
Drug utilization review
Basically a precertification program
Must document clinical need for a particular drug before
coverage allowed
Pattern review
Review prescribing patterns of physicians
Automatically send out communications to physicians with low
generic fill rates or high costs
Medical director may discuss with physician
Academic detailing
Physician-to-physician interaction
Often focused on specific drugs or conditions
Most effective approach
Very costly to perform
Managed Behavioral Healthcare Organizations
Legislation Affecting Behavioral Healthcare Benefits - The
Mental Health Parity and Addiction Equity Act passed in
October of 2008
The Patient Protection and Affordable Care Act (ACA)
Common Behavioral Health Specialties - Marriage/family
Child/adolescent
Substance use disorders
Eating disorders

13. Anxiety disorders
Lesbian/gay issues
HIV/AIDS
Faith-based counseling
Workplace/career issues
Managed BH Care
Four basic principals:
Alternatives to psychiatric hospitalization
Alternatives to restrictive treatment for substance abuse
Goal-directed psychotherapy
Crisis intervention
Three basic types of services:
Substance abuse
Basic mental health
Dual diagnosis
Types of Behavioral Health Services -Inpatient
Residential
Partial Hospitalization
Intensive Outpatient Program
Outpatient
Employment Assistance Programs (EAPs)
Goals of Treatment
Improve the BH status of a defined population
Improve the clinical status of a population in terms of
symptomatic distress levels
Improve life functioning in several areas
Aim to reduce suicide rates
Aim to reduce homicide rates
Aim to reduce substance abuse-related impairments
Aim to reduce mortality and morbidity from accidents related to

14. substance abuse or mental disorders
Behavioral Health Utilization Management
Traditional - Utilization Review (UR) to determine the medical
necessity of treatment typically includes
Preadmission certification of inpatient BH cases
Concurrent review of inpatient and residential cases
Case Management includes
Traditional UR
Extends into a broader form of patient advocacy
Addresses the longitudinal course of care as well as discrete
episodes of intensive treatment
Potential “gatekeepers” for managed BH system
Employee assistance program (EAP)
Primary care physician (PCP)
Mental health/substance abuse case manager and assessor
Strategies Evolving to Emphasize - Addressing the psychosocial
precipitants to admission to high levels of care in order to get
early treatment response and avert the need for admission
Behavioral Health Utilization Management
Increasing ambulatory follow-up to help prevent unnecessary
re-admission to high levels of care
Reducing re-admission through intensive interventions for at-
risk patients
Measuring and tracking clinical performance with a focus on
outcomes and efficiency
Reducing relapse through effective aftercare planning and use
of community and social supports
Coordinating services among multiple agencies and providers
Emphasizing the quality of services provided through
supervision, clinical rounds, live call and documentation audits,

15. analysis of complaints, patient and provider satisfaction
surveying, in-service staff training and outcomes tracking.
Through the management of patient and provider data gathered
over many years, MBHOs have developed national and regional
norms, by diagnosis, for higher levels of care. Routine decisions
can be based on these norms with review resources used for
complicated cases at high risk for re-admission based on past
history.
Reviews increasingly focus on how providers can improve the
quality and/or efficiency of treatment and how the MBHO can
assist through specialized services, such as intensive care
management.
Behavioral Health Utilization Management
Field care management programs, in which MBHO staff work
with patients in the community, have been found effective in
maintaining patient stability while reducing use of higher levels
of care.
Provider education and communication, based on outcomes
monitoring, have become the norm.
Partnerships between MBHOs and facilities or programs with
similar values has reduced front-end utilization management
and increased joint management by outcomes.
Quality Management in Behavioral Health
PDCA Cycle
Plan: Identify opportunity for improvement;
Do: implement interventions;
Check: measure affect of interventions; and
Act: adjust interventions/change interventions.
Reports from the Committee on the Quality of Health Care in

16. America of the IOM
Safe – avoiding injuries to patients from the care that is
intended to help them.
Effective - provision of services based on scientific knowledge
to all who could benefit and refraining from providing services
to those not likely to benefit (avoiding overuse and under use,
respectively).
Patient-centered – providing care that is respectful of and
responsive to patient preferences, needs, values and ensuring
patient values guide clinical decisions.
Timely – reducing waits and sometimes harmful delays for both
those who receive and those who give care.
Efficient – avoiding waste, including waste of equipment,
supplies, ideas, and energy.
Equitable – providing care that does not vary in quality because
of personal characteristics such as gender, ethnicity, geographic
location, and socioeconomic status
Data Sources for Behavioral Healthcare Quality Management
Performance Measures used for Quality Management
Accreditation of Managed Behavioral Healthcare Organizations
by NCQA or URAC
Week#2-To Do List-SMHS

17. Week 2: Readings
Please use the assigned course book to read the following
sections:
Part III: Management of Utilization and Quality
Chapter 9: Physician Behavior and Managed Health Care
Chapter 10: Data Analysis and Provider Profiling in Health
Plans Delivery Systems
Chapter 11: Prescription Drug Benefits in Managed Care
Chapter 12: Managed Behavioral Health Care
Internet Links
https://www.youtube.com/watch?v=zO5eagkdknk
https://www.youtube.com/watch?v=aEHSGUYAx7o
https://www.youtube.com/watch?v=2UJlD4S0s98
https://www.youtube.com/watch?v=ojRpQiDsbTM
Discussion-1
Discuss the types of forces in society with medical training in
particular in mind that make managing the behavior change of
practicing physicians a challenge.
Historical Analysis Paper-Written Assignment
The Evolution of Managed Health Care –
Select a specific time period of managed care development as
outlined in the textbook and lecture notes. Compare the events
of your selected period with the current time and discuss any
significant milestones that have been achieved, and areas that
still need improvement.