In 2012 it is essential to bring medical management well beyond traditional utilization management. The cornerstone of medical management revolves around clinical outcomes for membership. This entails:

• Stratifying the entire population monthly
• The top 5% of the population at greatest risk must be committed to a viable outreach program
• Combining the new integrated model incorporating physical, behavioral, and social concerns
• Including pharmacy information
• Wellness as a new foundation for population management

In addressing utilization management, it is time to recognize all efficient providers who will likely constitute the majority of the network; only the inefficient providers should receive traditional utilization management. Even this traditional approach should include more intense educational communication with these providers.

It is crucial both internally and externally for outcomes to be at the focal point of all organizations' efforts.

In 2012 and beyond, it is now not only desirable but actually will be mandatory to operate with defined goals and metrics within medical management. This absolutely means that all activities should have corresponding values within any area of medical management.

For more information about approaching Outcomes Medical Management, please contact us.