IMPROVE / Clinical Program Design
Clinically Correct. Economically Valuable. Patient-Centered.
Clinical management should improve quality, safety and value without turning administrative denial into the objective of the program.
Clinical-program framework
Three principles organize every program
1
QUALITY & SAFETY
- Clinical appropriateness
- Evidence-based criteria
- Safety
- Provider variation
- Clinical pathways
- Quality measurement
- Outcomes
- Risk identification
2
VALUE
- Appropriate utilization
- Avoidable utilization
- Medical-cost reduction
- Site-of-care optimization
- Modality selection
- Downstream cost
- Program economics
- Actuarial methodology
- Value-based reimbursement
- Provider incentives
3
ACCESS & EXPERIENCE
- Reduce unnecessary administrative friction
- Facilitate appropriate care
- Provider education
- Decision support
- Member experience
- Efficient authorization
- Selective intervention
One program, three tests
Clinically correct. Economically valuable. Patient-centered.
Utilization management
Utilization Management Without Making Denial the Product
Utilization management should identify inappropriate variation and guide better clinical decisions while allowing appropriate care to proceed with minimal friction.
Appropriate case
- Streamline
- Approve
- Proceed
Case requiring attention
- Identify
- Evaluate
- Educate
- Redirect or modify when clinically justified
Denial rate is not the primary measure of success. The model emphasizes educative clinical decision support rather than adversarial, denial-based review.
Clinical-program experience may include
- Radiology
- Cardiology
- Oncology
- Musculoskeletal
- Sleep
- Specialty Drugs
- Genetic Testing
- Molecular Testing
- DME
- Home Health
- Endoscopy
- Emergency Medicine
- Palliative Care
- Provider Quality
- Network Management
Next step
Design the program so the clinical logic and the economics agree.
Tell me which clinical area, which market and what the program has to prove.