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Here’s what that may mean for case managers
The new millennium has dawned and with it a new consumer-driven health care industry has arrived, according to a new PricewaterhouseCoopers report, Healthcast 2010: Smaller World, Bigger Expectations. The report was released at the corporation’s recent Thought Leadership Forum in Cambridge, MA. Case management industry leaders agree with that assessment, among other Healthcast 2010 report predictions, and say understanding the impact of this Internet-armed, better informed, more demanding consumer will provide both challenges and opportunities for tomorrow’s case managers.
"The need to become outstanding educators and partners of our patients will require case managers to take advantage of more opportunities than ever to keep current with rapidly evolving health care advances," says Kathleen Moreo, RN, BSN, BPSHA, CDMS, ABDA, CM, owner and president of Professional Resources in Management Education (PRIME), a case management consulting and education firm in Miramar, FL, and president of the Case Management Society of America (CMSA) in Little Rock, AR.
"In the near future, successful case management will mean good riddance to our too-often paternalistic care coordination, and hello to true, patient-centered, patient-driven approaches," predicts Moreo.
"We will assist the patient/family in accessing appropriate medical information and support the family/patient in mapping out individualized health care plans — much like financial planners assist clients with portfolio selections. We will assist families, employees, and seniors in determining health care choices, help them ask their physicians the right questions and ensure that information is documented in their care coordination records. We will provide assistance in selections of care maps for wellness coverage so that their health care is well-planned in advance — when they are healthy and able to make sound choices regarding their own at-risk disease processes," she says.
Just a little guidance, please
Others agree. "Consumers will take a more active role in their health care and will seek advisors to assist them in navigating that system," says Nancy E. Skinner, CCM, RN, principal consultant for Riverside Health Care Consulting and immediate past president of CMSA. "Case managers will be those advisors, and hospitals and physician groups will offer case management to consumers as a value-added service. Empowered consumers will privately hire case managers to maximize health care dollars, obtain information regarding alternative health care options, identify methods for receiving continuing care services in the home, and advocate for the delivery of quality health care services."
The days when consumers viewed providers as authority figures whose word was law is past, adds Skinner. "Baby boomers have established a pattern of challenging authority — asking questions and obtaining validation of those answers from multiple sources. Baby boomers are computer literate and will seek information via the Internet — not only from traditional sources such as professional organizations, but also from sources dedicated to complementary and alternative medicine [CAM]."
Skinner predicts that baby boomers will expect Medicare to provide expanded coverage for CAM. Additional impacts Skinner expects aging baby boomers to have on the health care marketplace include:
• More pressure on government officials to improve benefits. "More pressure will be placed at all levels of government to provide quality health care services, including pharmaceuticals and coverage of traditional therapies," says Skinner.
• More retiree programs. "We will also see an expansion of employer programs for their retirees that is secondary rather than supplemental to Medicare, she says.
• More direct-to-consumer advertising by providers. "Physician groups, hospitals, pharmaceutical companies, home health agencies, rehabilitation facilities, and other continuing care providers will all increase direct advertising to the consumer. This advertising will be in both print and electronic media," says Skinner.
Yet, while many point to the new, educated, well-informed health care consumer, others caution that not all consumers have jumped into the information age with both feet.
"The problem is that there is still a large group of people who are not catching onto this excitement and they are the ones case managers often work with," says Anne M. Llewellyn, RN, CCM, CRRN, owner of PRIME. "Those are the poor and uneducated, who often make poor choices. This is the 20% of the population that utilizes 80% of our health care resources. The case manager’s goal will be to identify this population and work with them to educate them about their health issues and cut through the red tape that seems to trip these people up in life."
Llewellyn points to another prediction of the PricewaterhouseCoopers report as a possible solution to some of the problems common to this 20% of the population that consumes so many health care resources — e-commerce.
She offers the following scenario to illustrate how e-commerce will improve health care services in the very near future:
An HIV-positive patient who is noncompliant with his medication regimen and also an IV drug abuser comes into an emergency room on a Saturday night. His personal physician is in another state. The patient has been visiting his mother for the past two months. He states he is on a "ton of meds," but did not bring them with him.
Today, the attending emergency room physician must start from scratch with this patient. In the future, that same physician could access the patient’s records through the computer. The treating physician could access the current treatment plan and also read the patient’s primary physician’s notes regarding the education the patient has received about his IV drug abuse and noncompliance. This gives the new physician a place to start instead of reinventing the wheel. It also gives the case manager a clear idea of this patient’s needs and the tools to begin an aggressive education effort. This patient will get better and more appropriate care because of technology. Instead of starting over, there can be true continuity of care.
PricewaterhouseCoopers interviewed and surveyed 400 thought leaders and health care executives in the United States, Europe, Canada, and the Pacific Rim about their predictions on the factors shaping the future of health care. The report also predicts a rise in genomics and a health care paradigm shift to a prevention model. In fact, 38% of the survey respondents in the United States predict that third-party genetic mapping businesses will spring up and become the primary source for an individual’s genetic map.
"Genetic mapping may become more available and with it will be a need to answer ethical questions that are tied to these services. Will a genetic tendency to develop catastrophic disease interfere with a consumer’s ability to receive appropriate health care coverage? Will case managers work with consumers who have these genetic tendencies to develop appropriate strategies to address anticipated health care needs?" Skinner wonders.
Too close for comfort
Perhaps no area of the report hits closer to home for case managers than Healthcast 2010’s predictions for how the industrialized world will pay for tomorrow’s health care. Pricewater-houseCoopers’ thought leaders predict that health care financing trends will converge, with the United States moving toward a more governmental model and Europe and Canada moving away from a government model toward more privatization.
Specifically, the survey found:
• 60% of respondents believe that most American employers will offer employees the option of medical savings accounts by 2010.
• 64% of respondents think employers will move to defined contribution programs for health benefits.
• 56% of respondents predict that Medicare also will move to a defined contribution program for health benefits.
Moreo also expects employers to offer medical savings accounts and sees that as an opportunity for case managers to educate consumers. "In South Africa, for example, medical savings accounts are already offered to employees in private industry and are fraught with problems," she notes. "All medical savings accounts are capped per annum, and can roll into major medical depending on the intensity of service. Due to caps, parents often disregard their own health needs in order to protect the savings for their children. This is a nationwide problem in South Africa. Further, physicians are falsifying the intensity of service necessary for patients in order to help their patients save their medical savings, accessing major medical funds, instead. As these medical savings accounts become available to consumers, case mangers must take a role in educating employees about their best use."
Paying for tomorrow’s health care is a problem that every country is facing, says Llewellyn. "With the aging of our world and the slow population growth, we will not have the support that has been previously in place," she predicts. "Employers will pull out of the insurance business and this will become the responsibility of the individual and for those who cannot afford the cost of health insurance, the government will step in.
"Due to these pressures, consumers, case managers and others in the health care system will need to deal with issues regarding end-of-life that up until now we have not always been willing to tackle," adds Llewellyn. "The 99-year-old woman living in a skilled care facility in a fetal position who develops a fever will not be as aggressively treated as she would be today. Quality of life will have to be looked at and hard decisions will need to be made. This is slowly coming into play, but will really become a reality when the family of that 99-year-old woman has to pay the bill themselves. This will take education and support."
In addition, Llewellyn sees the chronically ill needing to take increasing responsibility for their own health care.
"The pressure will be on all health care workers to deal with this, but I see the role of the traditional case manager becoming more prominent if we are willing to take the challenge," she says. "The role of the traditional case manager will change to deal with that 20% who spend the 80% of our health care resources in an aggressive manner that recognizes that we do not have an endless supply of money and choices have to be made. Case management has tremendous potential if we are willing to change, learn, and take the lead in shaping health care policy. The case manager is the one professional who has the foresight to understand the holistic needs of the customers who use the health care system."
"We can all take a look at trends and guess what the future may hold," Skinner concludes, "but I firmly believe that the role of the case manager will be significant in tomorrow’s health care delivery system. I believe that case management will come out of the closet to become a powerful consumer tool for establishing the delivery of quality, appropriate, and cost-effective care both in this country and internationally."
The PricewaterhouseCoopers’ Healthcast 2010 report is available on the company’s Web site at www.pwcglobal.com/healthcare.