Controlling Costs and Changing Patient Care? The Role of Utilization Management (1989) / Chapter Skim
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High-Cost Case Management
High-Cost Case Management
Pages 119-142
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From page 119... ...
Virtually all major commercial insurers and Blue Cross and Blue Shield plans offer the service either directly or through subsidiaries (Henderson and Wallack, 1987) , as do most of the larger utilization management firms and third-party administrators.
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From page 120... ...
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 SociaVHealth Maintenance Organization demonstration projects for the elderly in the 1980s (Merrill, 1985~.
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From page 121... ...
, however, is planning demonstration projects to assess the role it might play, ,iven Medicare's special characteristics. For payers whose method of paying hospitals does not, n itself, stimulate hospital discharge planning, continued-stay review may be used to prompt its
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From page 122... ...
In addition, OPM does not ask for reports on costs or savings achieved through high-cost case management (Eileen Thomas, Blue Cross and Blue Shield Federal Employees Program, personal communication, November 22, 1988~.
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From page 123... ...
that would be provided for specific patients in the absence of case nanagement; · willingness to approve payment for services not covered by the atient's benefit plan, if doing so will help reduce overall costs; and · concurrence from all relevant parties-patient, family, and physiian-in implementing cost-saving alternatives for meeting the patient's feeds. Although the first two of the above elements appear to be virtually universal in high cost case management programs, the third element is not, even though it is often described as part of a standardized model.
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From page 124... ...
124 · Prior Review CASE NOT APPROPRIATE CONTROLLING COSTS AND CHANGING PATIENT (CARE? CASE IDENTIFICATION · Call from Patient, Employer, Provider ASSESSMENT OF PATIENT · Claims history examined · Additional information collected by telephone or site visits PLAN DEVELOPMENT · Alternative methods and sites of treatment evaluated, AND · Specific treatment plan developed, suppliers of services located, limits of benefit plan identified, AND · Agreement to plan obtained from some OR all of the following: patient, family, physician, employer PLAN IMPLEMENTATION AND MONITORING · Arrangements with service suppliers completed, AND · Transfer of patient coordinated, AND · Claims for payment reviewed, AND · Patient status and services monitored and adjusted if needed CASE CLOSURE · Recovery · No further benefit form case management FIGURE 5-1 Examples of steps and variations in case management · Claims Payment Screen ~ 1 CASE ACCEPTED · Maximum coverage limits exceeded · Death
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From page 125... ...
Operational Variations The committee learned during its site visits that high-cost case management programs are highly variable in ways that are not always easy to describe. The narrowest programs are, in essence, hospital discharge planning programs that operate by means of telephone and confine themselves TABLE 5-1 Typical Case Management Summary and Analysis CONFIDENTIAL CASE REPORT 1 Patient: YYYY Referred by: VVVV Prepared by: WWWW Diagnosis: Lymphoma INllIAL CASE SUMMARY Client: X~ Date Opened: 2/14/88 Date closed: 3/9/88 Patient is a 56-year-old woman with terminal breast cancer.
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From page 126... ...
Hospital days averted: 75 at $1,200/day Rehabilitation hospital days averted: 21 at $900/day Actual home care expenses: $8,000 Case management fee: $6,200 SAVINGS Hospital costs averted: Rehabilitation costs averted: Home health expenses: Fee: Net savings $80~000 $18~900 ($8~000)
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From page 127... ...
In addition, an employer's disability insurance plan may refer cases for high-cost case management. If the organization providing high-cost case management also provides other utilization management services, it may use its preadmission, admission, and continued-stay review programs to identify patients that are candidates for preadmission review.
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From page 128... ...
They often speak of a "team approach" to case management in which several types of professionals contribute to patient assessment and recommendations. How Case Managers Relate to Patients and Providers Most high-cost case management programs report that they seek to work with all interested parties the patient and family, the doctor, the 3Blue Cross and Blue Shield plans that pay hospitals on a diagnosis-related group (DRG)
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From page 129... ...
the attending physicians have essential information about the patient and he course of treatment, can influence patients' and families' acceptance if case management recommendations, and can assist in implementing ecommendations by approving hospital discharges, ordering or providing necessary medical services, or supervising the care provided by others. Face-to-face work with patients and physicians is most characteristic of dMOs and utilization management programs that operate in a relatively onfined geographic area.
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From page 130... ...
How Much Case Management Costs Another variable factor with high-cost case management programs is their cost, whether cost is defined as the price the purchaser of the service pays or the resources the utilization management organization requires to operate (Henderson and Wallack, 1987; Cologero, personal communication, 1988~. Some insurers have not explicitly charged for case management services but have incorporated the cost as part of their premium or administrative services charge.
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From page 131... ...
For the 30 cases actively managed in that year, it reported savings of nearly $2 million, over $65,000 per case on average (Independence Blue Cross and Pennsylvania Blue Shield, 1988~. Intracorp, a firm with a history in case management in the workers compensation arena, has reported savings as high as $75 for every dollar spent on case management.
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From page 132... ...
Effects on Enrollees In discussions with those offering and purchasing high-cost case management services, most recounted with some feeling-stories of individuals who have been assisted by case management in confronting devastating medical problems. Even in the less dramatic cases, the picture conveyed is of people who are grateful for additional information, guidance, and support in dealing with stressful and complex situations.
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From page 133... ...
For the attending physician and hospital discharge planner, the case manager can often bring to bear a more specialized knowledge of certain alternative treatments and providers and a more intensive assessment of patient circumstances and options. For example, the case manager may know more about innovative rehabilitation services or specialized home care options and have established relationships with these providers so that it is easier to tailor services for particular patients.
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From page 134... ...
On the other hand, certain characteristics of case management programs can make their evaluation easier. One characteristic of high-cost case management that facilitates evaluation of utilization and savings is the explicit focus on the cost-effectiveness of proposed alternative care.
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From page 135... ...
UTILIZATION Inpatient days of care projected without case management Alternative services (projected or actual) Home health Skilled nursing facility Durable medical equipment Other Source BENEFIT COSTS Claims data Review organization Comments · Projected utilization of hospital care is easy to overstate, particularly during periods of changing practice patterns.
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From page 136... ...
SAVINGS Projected cost of care without intervention minus high-cost case management benefit and administrative costs Ratio of benefit savings to benefit and adm~n~s~ative costs Source Claims data Review organization Comments . · See comments on use and cost measures.
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From page 137... ...
44~. Longer-term savings were not studied in the initial assessment because they were both harder to track and more speculative.5 Although the relatively small number of patients in most high-cost case management programs has some advantages for evaluation purposes, it also means that the mix of cases- and program effects can fluctuate for reasons unrelated to the program or to other systematic influences.
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From page 138... ...
Such improvements seem likely because of several types of changes in case management programs. These include · better targeting and earlier identification of cases, · elimination of overlapping cost-containment efforts, increases in administrative efficiency and computer support, development of standardized clinical protocols to guide the management of more cases, and establishment of more economical and effective arrangements with health care providers.
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From page 139... ...
Therefore, some case management programs are trying to develop better early identification strategies such as having predetermination software screen each pneumonia case for age and sex of patient and any previous admissions. Sensitivity to confidentiality is a particular concern for this kind of approach, but confidentiality issues are significant for many high-cost care management cases.
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From page 140... ...
Some employers, citing sensitivity about perceived conflicts of interest, are reluctant to have their own physicians or other employees involved in high-cost case management and prefer to hire outside firms instead. Actions that might put an organization at risk are the use of poorly selected and trained personnel, negligent referrals to particular providers, and poor protocols for collecting information about patients' conditions.
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From page 141... ...
And these procedures should be implemented responsibly and documented systematically for both routine and exceptional cases. Evidence of careless, biased, and uninformed decision making is hazardous whether a complaint involves a routine payment denial, a bad health outcome, or a charge of discriminatory treatment.
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From page 142... ...
Health Insurance Association of America, AIDS Case Management: What Health Insurance Companies Are Doug, Washington, DC, 1988. Henderson, Mary, and Collard, Anne, "Measuring Quality in Medical Case Management Programs," Squalid Review Bullean, February 1988, pp.
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