Strong market forces are challenging health plans to objectively and clinically relax prior authorization and utilization management (PA/UM) efforts. For instance, the American Medical Association (AMA) published the 2019-2020 PA/UM Reform Principles, supported by more than 50 provider healthcare organizations. Main reform principles are: health plans should restrict PA/UM programs to ‘outlier providers’ whose ordering patterns differ significantly from their peers; and health plans should offer providers at least one clinically-based alternative to PA, such as ‘gold-carding’ based on clinical decision support systems.
Moreover, the BlueCross BlueShield Association (BCBSA) Consensus Statement on Improving the PA Process shows strong Blue Plan commitment to relax PA/UM efforts for those health systems and provider groups that are ‘non-outliers’. Non-outliers are identified through the implementation of a clinical decision support system that retrospectively examines provider performance and adherence to evidence-based medicine.
“For over a decade, CCGroup has remained the market leader in offering a clinical decision support system based on medical condition, clinically appropriate ranges of clinical practice,” stated Dr. Douglas G. Cave, President/CEO of CCGroup. The clinical decision support system is CCGroup UR/UM-View™. Medical condition MedMarkers™ and associated Clinical MedMarker Protocol Ranges™ are the foundation of CCGroup UR/UM-View™.
“CCGroup is the only company in the market that has developed MedMarkers™ for all prevalent medical conditions treated by each physician specialty type,” asserted Yuri Alexandrian, COO/CIO of CCGroup. MedMarkers™ are process of care quality measures, well-defined in clinical guidelines. However, MedMarkers™ also are the key services and procedures most associated with cost-of-care in treating a medical condition. MRI of spine is the main MedMarker™ (or correlated service) in treating low back pain; and upper gastrointestinal (GI) endoscopy is the main MedMarker™ in treating GERD (or heartburn). MedMarker™ technology is protected under USPTO Patent Numbers 8,301,464 and 8,751,283 and 9,881,129 and 10,319,474.
“Clinical MedMarker Protocol Ranges™ are achievable and clinically appropriate ranges of clinical practice for MedMarkers™. These ranges are developed by presenting the CCGroup National Comparative MedMarker Database™ results to CCGroup National Specialist Panels. Specialists on a CCGroup National Specialist Panel need to have an academic appointment or affiliation at a targeted, well-respected U.S. medical school – and at least 75% of their direct clinical practice is in patient care,” defined Dr. Cave. Clinical MedMarker Protocol Range™ technology is protected under USPTO Patent Number 10,867,361.
Each specialist on a CCGroup National Specialist Panel is asked to review medical condition MedMarker™ results. Then, they decide the percentage of patients where a MedMarker™ service is likely clinically warranted. The specialists also are instructed to ensure the percentage of patients having the MedMarker™ is not too low to represent under-utilization of care.
Dr. Cave stated, “Based on the CCGroup National Specialist Panel results, the appropriate Clinical MedMarker Protocol Range™ is selected for each medical condition. For example, the acceptable Clinical MedMarker Protocol Range™ for routine low back pain is no more than 0-to-20 out of every 100 episodes with an MRI of spine.”
CCGroup recently re-surveyed cardiology, orthopedic, general surgery, dermatology, and urology CCGroup National Specialist Panels. Working with the CCGroup National Specialist Panels is an important part of CCGroup’s ongoing efforts to support established Clinical MedMarker Protocol Ranges™ and our clinical decision support system – CCGroup UR/UM-View™.
“Based on re-survey results, there are few-if-any changes to the existing Clinical MedMarker Protocol Ranges™. For illustration, the established Range for essential hypertension (the medical condition) is 5-to-35 out of every 100 episodes with an echocardiogram (the MedMarker™). Our recent re-survey confirms that this is an acceptable clinical range,” declared Dr. Cave.
CCGroup UR/UM-View™ objectively assigns a PASS (non-outlier) or FAIL (outlier) ranking to each cardiology group – with respect to PA relief clinical requirements. “There are 50 clinical rows to evaluate cardiologists’ clinical practice. A clinical row is comprised of a medical condition, an associated MedMarker™, and an established Clinical MedMarker Protocol Range™,” defined Mr. Alexandrian.
For each clinical row, a cardiology group needs to practice within the Clinical MedMarker Protocol Range™. If the cardiology group practices within a Range more than 80% of the time (or 40 of the established 50 clinical rows), then the cardiology group receives an objective PASS (non-outlier) ranking; if not, a FAIL (outlier) ranking is assigned. CCGroup UR/UM-View™ objectively PASS/FAIL ranks all 50 of the top specialty and sub-specialty types.
About Cave Consulting Group, Inc. (CCGroup)
Cave Consulting Group, Inc. is a software and consulting firm located in San Mateo, California. The company is focused on improving the efficiency (cost-of-care) and effectiveness (quality-of-care) of the healthcare delivery system. Senior management of CCGroup has assessed the performance of physicians and hospitals for over 29 years for health plans, health systems, HMOs, physician groups, CINs, ACOs, TPAs, and employers.