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is one prominent strategy (Health Insurance Association of America, 1988; Taravella, 1987).
Because the case manager is not managing care as a physician does but rather is trying to see that health plan benefits are used wisely, some organizations prefer to call their programs "individual benefits management." Other organizations, reluctant to highlight cost objectives, use the term "medical case management."
Focus of High-Cost Case Management
What distinguishes high-cost case management from other utilization management or managed care programs is its intensive and specialized focus on high-cost medical cases. Preadmission and continued stay review, in contrast, cover a broader array of cases in a much less intense fashion.
The generic label "case management" seems to have arisen in the 1970s with government projects to encourage the integration of services for clients of social welfare programs (Monroe County Long Term Care Program, Inc., 1986). These include the Services Interaction Targets for Opportunities program in the 1970s and the channeling and Social/Health Maintenance Organization demonstration projects for the elderly in the 1980s (Merrill, 1985). High-cost case management shares with other case management approaches an emphasis on assessing individual needs and circumstances and then planning, arranging, and monitoring needed services. However, because it focuses on a relatively small number of expensive cases, high-cost case management can be distinguished from so-called primary-care case management approaches often used in HMOs and Medicaid programs. In these programs, all individuals are assigned to a case manager who ordinarily must authorize or provide most services. And because health care cost containment is a central goal, high-cost case management can be distinguished from social welfare case management that is aimed at helping clients get the services they need from the complex labyrinth of welfare programs and agencies.
In focusing on very expensive patients, high-cost case management responds to an important characteristic of medical care: a small group of individuals with very costly illnesses or injuries account for a large share of the total expenditure. The experience of one company is typical: 2 percent of plan members with yearly expenses of $10,000 or more accounted for 38 percent of plan medical expenses (Rosenbloom and Gertman, 1984). In another company, 6 percent of those making benefit claims (and not all employees submit claims) accounted for more than 55 percent of health plan expenditures (Alexandre, 1988). National data suggest that 1 percent of the U.S. population (all age groups) accounts for 29 percent of total