Optimal Utilization Management Model for Martin Army Community Hospital Under the Next Generation of TRICARE Contracts

摘要

The next generation of TRICARE contracts makes substantial changes in the business operation of our military health care delivery system. The largest area of change is in utilization management (UM). Under the new contract, the government will be responsible for all aspects of health care management of prime enrolled beneficiaries to include underwriting the cost of care in both the direct care and purchased care sectors. The new contract makes the government responsible for the purchased care authorization process to include medical necessity review, continued stay review and coding of all medical, surgical and behavioral health episodes of care. The government also becomes responsible for the appeals process for any denied episode of care. This research project was conducted to determine the optimal UM structure for Martin Army Community Hospital (MACH) under the new contract considering the current UM structure at MACH, the impact on beneficiaries, and fiscal constraints. Four models were developed and analyzed using the criteria of least negative impact on the beneficiaries and financial viability. The optimal model costs $451,000 and has minimal impact on the beneficiary population.