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Family Medicine & Community Health Elective Course Description

Course Name: Evidence-Based Medicine in Health Policy: An Introduction to Medical Necessity Guidelines and Utilization Review
Course Number: FC-458
Elective Type: C

Monica Le, MD

Contact: Karen Rayla 

Department: Family Medicine & Community Health
Sites Available: Quincy, some main University campus
Months Offered TBD
Number of Students/Month: 1
Prerequisites: UMass Chan students only
Enrollment Process: Approval from coordinator required; email approval to to schedule

Elective Description: Ever wonder how doctors get paid? Understanding the structures for payment for evidence-based, high-quality care is essential in the current practice of medicine. This elective offers a unique experience in a public payer setting through the Office of Clinical Affairs (OCA) which provides clinical leadership to MassHealth, the Massachusetts Medicaid program.  OCA is a part of the Center for Health Policy and Research within ForHealth Consulting, the healthcare consulting arm of the University of Massachusetts Medical School.  In this elective a student will learn to assess outcomes data and best practices to contribute to the development of medical necessity guidelines for medical procedures and pharmacologic agents. The experience involves a combination of independent work and shadowing senior health policy leaders in the public payer setting.

Objectives By the end of the rotation the student will understand how clinical leaders and public payers:

  • Determine health policy priorities
  • Develop medical necessity guidelines—the rotator will contribute to the drafting of a guideline
  • Assess the evidence-based literature for quality of evidence
  • Assess the existing health policy landscape
  • Conduct utilization reviews

Depending on interest and availability, activities may include:

  • Selection of a topic for development of a medical necessity guideline for a medical procedure by:
    • Preliminary literature search and comparison of other payers’ policies (both other public and other private payers)
    • Review guideline feasibility process
  • Training in how to conduct a literature review and assess for quality of evidence
  • Review of pertinent information
  • Development of the first draft of a medical necessity guideline
  • Conducting an environmental scan of multiple payers’ policies
  • Attendance at hearings for denied prior authorization requests
  • Attendance at MassHealth Pharmacy Policy meetings for discussion on new drug reviews, quality assurance, etc.
  • Shadowing clinical reviewers of the drug utilization program –rotator will observe prior authorization reviews and pharmacy customer service calls.

Preceptors: Christina Dorell MD, Umbereen Nehal MD, Kim Lenz PharmD, Joshua Twomey PhD, Deborah Parker MBA