IGC - Managed Care Program Goals & Objectives

(IGC Preceptorship III & IV only)

Upon successful completion of the assigned managed care sessions, the student will be able to assess the impact that managed care might have on a physician’s practice (i.e., educational experiences with a minimum of three out of the eight areas below):

1. Utilization Management (In-House): By observing the pre-certification and authorization processes with an authorized representative of a managed care organization, the student will be able to examine the use of specific medical criteria, assignment of length of stay, and the denial process.
   
   
2. Utilization Management (On-Site): By making medical rounds with an onsite (hospital) review nurse or a hospitalist physician, the student will be able to examine the application of length of stay criteria and the determination of medical necessity for continued hospital stay. The student will also have an opportunity to examine the hospital discharge planning process and to understand the concept of continuity and coordination of care.
   
   
3. Case Review/Rounds: By observing the health plan’s "grand rounds" of the review of hospitalized patients, the student will be able to cite three examples from one of each of the following: (a) how medical criteria impact in-patient admissions/length of stay; (b) initiation of case management; ( c ) the steps taken in the discharge planning process; (d) inpatient disease management; (e) the concurrent review process; (f) the steps taken by the MCO to ensure for the most cost-effective delivery of care.
   
   
4. Case/Disease Management: The student will be able to analyze the the benefits of utilizing a population-based approach to the prevention and management of chronic and catastrophic disease by reviewing various approaches to the case management of patients enrolled in disease/illness management programs (e.g., asthma, diabetes, CHF, renal failure, high-risk pregnancy) conducted by the case manager.
   
   
5. Quality Management/Improvement: The student will be able to analyze how an MCO monitors and maintains the health care and services provided to its members to promote adequate access, acceptable outcomes, cost-efficiency, patient satisfaction and effect improvements as needed. The student will also be able to recognize the importance of appropriate medical record documentation, and will understand the various practice guidelines that MCOs follow.
   
   
6. Provider/Practice Management: The student will be able to analyze the process of provider management including credentialing, contracting, compensation models, provider orientations/education, procedures for referrals, authorizations, record-keeping, and billing issues.
   
   
7. Medical Operations: Through discussions with the medical director of an MCO, the student will be able to recognize factors that determine medical necessity, application of benefits, physician education, and the interrelationship with the plan’s physician network.
   
   
8. Committee Meetings: By attending physician committee meetings (e.g., Peer Review, Credentialing, Pharmacy & Therapeutics, Quality Improvement), the student will be able to recognize the important role that physicians play in ensuring for the quality of care delivered by MCOs.

Duration of Managed Care Sessions

M1 Students: 2 didactic auditorium programs/year (@ 1 - 2 hours/lecture) = 3 hours/year

M2 Students: 2 sessions/year x 4 hours/session = 8 hours/year with MCOs

3 didactic auditorium programs/year (on practice management, medical economics and managed care delivery systems) @ ~ 2-3 hours/lecture) = 7 hours/year

Managed Care Total: 18 hours (M1 + M2 years)