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Case management and utilization management, two of the pillars of managed care, are being brought in-house by capitated physician practices intent on assuming these functions, which traditionally have been performed by managed care organizations.
"As groups take on more risk, case management becomes more appropriate," says Lynne Emma, RN, MPH, vice president of population health at HealthCare Partners, a Los Angeles-based integrated delivery system. "It doesn’t make sense to have a health plan that’s not delivering care making medical decisions. It should be a clinical care decision."
Most practices would agree with that line of reasoning. But how do you get a managed care organization to delegate that authority when you’re talking about an area that MCOs have traditionally been heavily involved in? Use your credibility and data that show your physicians are capable of managing care efficiently, according to Emma. And it doesn’t hurt to have good contract negotiators on your side, adds Jim Pyle, executive vice president of Dallas-based Medical Directions Inc., which has a number of client practices that are considering in-house case management. Pyle says it can mean revenue of 1% to 3% of the premium dollar, depending on the degree of case management a practice takes on.
In-house case management can be organized in a variety of ways. Here is how two practices have approached it.
• HealthCare Partners.
At 250,000-member HealthCare Partners, the practice focuses on case management (moving patients through the entire care process) rather than utilization management (pre-certification of medical decisions such as recommended hospital stays or treatments). Little prospective review of medical decisions is done, with the exception of a few red-flag procedures such as transplants or any second medical opinion. In these cases, a physician-run medical review committee discusses any cases that have recommended treatments on the red-flag list, which represent a small percentage of HealthCare Partners’ cases.
HealthCare Partners is able to limit its utilization management review because the practice has built up credibility over the years with the 18 managed care organizations it contracts with, Emma says. It also has spent a great deal of time educating physicians so they know how to make sound judgements on what should or shouldn’t be approved. Weekly regional meetings among medical directors and physicians offer on-the-job training based on case discussions raised during these meetings, Emma says.
By allowing physicians to make medical decisions without utilization review, this frees up HealthCare Partners’ physicians and registered nurses on staff are freed up to focus on case management. HealthCare Partners takes a team approach to the function, organizing its inpatient case management into four geographic teams. Each geographic team includes a hospital intensivist, a HealthCare Partners-employed physician (usually a critical care physician) who is assigned to monitor all HealthCare Partners patients receiving inpatient care at the particular hospital the physician is assigned to.
Another member of the team is a case manager, a registered nurse who is assigned to patients in a specific hospital. The case manager attends patient rounds and meets daily with the hospital intensivist, and is responsible for keeping each patient’s specialist and family informed of the patient’s status. The case manager, employed by HealthCare Partners, also helps with transition planning if a patient needs follow-up care after leaving the hospital.
Ambulatory case management for outpatient care is done on a much more limited basis, although Emma says HealthCare Partners plans to grow this area of the business as it builds its disease management activities. Ambulatory case managers work with social workers in each geographic region to coordinate care for medically and socially fragile patients, primarily elderly people. They coordinate activities ranging from home care options to behavioral health care.
• Carle Clinic.
Carle Clinic, a 300-physician multispecialty group that operates a physician-owned HMO, takes an different approach from HealthCare Partners. Rather than doing case management for every patient internally, Carle focuses its case management efforts on frail elderly and some non-elderly patients, says Cindy Fraser, director of Carle’s Health Systems Research Center.
Carle right now is focusing its efforts on its Community Nursing Organization project, which is part of a HCFA demonstration project for Medicare patients. Although nurses have the autonomy to preauthorize select non-physician, non-institutional services needed (for example, home health services and outpatient therapies), Carle has found it best for nurses and physicians to work together as a team, Fraser says.
"We’ve found that the more you can pull those nursing functions closer into a more collaborative role with the physician who is typically ordering tests and special procedures, the better," she says. "The more they can work closely together and develop a partnership, the more rounded the services can be for a patient and the more seamlessly the system can function."
The nurse is responsible for assessing patient needs and incorporating community resources that can help a patient remain independent as long as possible, and is responsible for writing up a care plan summary, which facilitates communication and joint decision-making with the physician, Fraser says. The nurse also has the autonomy to visit each patient at home as needed.
For practices considering following HealthCare Partners and Carle’s example, here are some tips from Emma and Pyle:
1. Make sure your organization has the supporting systems and people with appropriate competencies to handle case management. Emma’s rule of thumb is to assign one registered nurse for every 10,000 to 12,000 patients. Staff you hire should have experience relevant to the types of contracts your practice has, Pyle says. Case management experience with a PPO is very different from experience at a tightly managed HMO.
2. Have a clear understanding of the difference between utilization management and case management. Utilization management involves approving procedures for medical purposes or making sure treatments recommended are covered under a member’s contract, while case management involves directing a patient’s medical progress over the entire spectrum of the health care delivery process.
3. Make sure your infrastructure includes the scope of all the services you need to provide. Some of these services may need to be added on gradually until you feel your practice is ready to take on the case management function, Pyle says. "It’s organic in nature," Pyle says. "You need to have utilization management, quality assurance, tracking systems. You can’t open your doors and put everything in place at one time."
4. Monitor your continuum of care component. If you plan to subcontract out any ancillary activities, make sure you have good arrangements. Your practice will be held accountable for both costs and quality of care delivered by these vendors.
5. Invest in provider education in utilization management and case management. HealthCare Partners has found that the most successful avenue for this is to model behavior among senior physicians at weekly regional medical meetings in which cases are reviewed. Physicians will see the kinds of things that are routinely approved and that receive further scrutiny.