The trusted source for
healthcare information and
Below is a checklist extracted from Michael J. Yedidia's research team’s accounting of core competencies of managed care, as identified by their surveys. Yedidia, PhD, is a professor of health and public service at New York University in New York City:
• Economics — Evaluate managed care organization contracts and compensation plans on the basis of their incentives for particular practice behaviors.
• Ethics — (1) Act on ethical principles in resolving conflicts that may arise if it is decided that a patient needs procedures or services that are not covered by a managed care organization. (2) Explain the reasons for a decision to allocate resources to serve the needs of populations at the potential expense of individual needs.
• Managed care and health care delivery — (1) Predict the impact of different payment arrangements on consumer and practitioner behaviors within a specific health care environment. (2) Act as a resource on aspects of managed care practice for colleagues who have not had training in this area.
• Managing multiple managed care organizations — (1) Reconcile your own treatment approaches with the potentially contradictory guidelines of multiple managed care organizations. (2) Adhere to the regulations of several managed care organizations in implementing referrals and ordering procedures.
• Practitioner morale and satisfaction — Develop a program updating the knowledge and skills of your colleagues and addressing practitioner morale and satisfaction.
• Clinical epidemiology — Determine the effect of a positive or negative test result on the probability that a patient has a particular medical condition.
• Cost-effective clinical decision-making — Weigh the costs vs. the probable yield of a particular diagnostic procedure in managing a patient with a specific medical condition.
• Evidence-based medicine — Locate and critically evaluate research evidence and apply one’s own conclusions to the care of an individual or patient group.
• Patient satisfaction — Interpret patient satisfaction data to make appropriate changes in practice operation.
• Population-based medicine — Use data on patients’ communities and environments to design tailored strategies to reduce the incidence of undiagnosed conditions.
• Practice guidelines — Adapt clinical guidelines based on evaluation of evidence from relevant research.
• Prevention — Use data on patient population to design and evaluate a disease-specific prevention programs.
• Time management — Use time efficiently in the clinical encounter to maintain quality of care while sustaining an adequate flow of patients.
• Case management — For patients with complex disease processes, ensure access to necessary clinical services, coordination of care, and efficient use of resources.
• Collaboration — (1) Assess the roles of all practice personnel in regard to patient education and institute a plan for making better use of their expertise in this area. (2) Delegate responsibility and share authority with nurse practitioners and/or [physician assistants] to ensure productive teamwork.
• Gatekeeping — Perform the "gatekeeping" role for a panel of patients, maintaining quality and cost-effectiveness of care.
• Referral management — Evaluate referrals to specialists for appropriateness and quality and initiate strategies for improving their effectiveness.
• Clinical efficiency — Conduct time and work flow analysis to enhance productivity.
• Continuous quality improvement — Identify clinical conditions appropriate for quality improvement projects and participate in implementation.
• Practice profiling — Compare one’s own practice profile to those of peers and make appropriate changes in one’s practice behavior.
• Utilization management — Weigh the benefits of case-by-case concurrent review vs. practice profiling in addressing a particular clinical issue.
Based on their surveys, the researchers found that a majority of medical training program directors favor teaching mastery of these "essential tasks." Currently, the study’s surveys show that about 40% of the programs surveyed are addressing two-thirds or more of the tasks.
Source: Yedidia M, Gillespie C, Moore G. Specific clinical competencies for managing care: Views of residency directors and managed care directors. JAMA 2000; 284.