A well-developed medical management program must be both administratively efficient and clinically sound, as well as relevant to the physician and patient populations being served. The program's policies and procedures guide and support the physician in making clinical decisions. Thus, physicians must be encouraged to participate in their development and ongoing improvement. Member Satisfaction Medical management programs promote satisfaction through the provision of tools to assist members in staying well, optimal management of chronic conditions, and provision of support and service coordination during times of acute crisis. For example, one such tool is a case manager who explains the course of treatment, assesses benefits to optimize coverage, coordinates multiple care providers, and is available to answer questions that arise as members move through levels of care is appreciated by those who require it.
Data Needs Medical management program outcome data can assist other areas in their performance.
In an MCO utilization data forms the basis for underwriting, rate setting, determining incentive payment, or withholding returns. In a physician organization such data is used to determine adequate capitation and target areas for improvement. Quality management outcomes support credentialing and incentive payment decisions for both types of organizations. Medical Management Components Medical management programs focus on service delivery and maintaining high levels of customer satisfaction, often surveying members regarding their satisfaction with care, the process used to arrange care, and the vendors who provide the care. Risk Reduction MCO medical management programs seek to identify at-risk patients, and then reduce that risk and promote appropriate access to care.