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The realities of health care today underscore the need to demonstrate measurable bottom-line outcomes. But Stefani Daniels, RN, MSHA, managing partner of Phoenix Medical Management (PMM), based in Pompano Beach, FL, argues that with physicians driving upward of 80% of resource costs, it’s equally important that case managers understand how they can leverage the challenges confronting physicians and hospitals to create program value for enhanced funding and a competitive advantage.
Not only has patients’ trust in health care practitioners waned, physicians and hospitals trust each other less as well, Daniels says. "There used to be a point in time where doctors and administrators worked together," she says. But that has been replaced by an adversarial relationship that also includes payers.
Worse yet, the doctor-patient relationship had become a myth, Daniels argues. The average time that a doctor spends with a patient is six minutes. "What kind of relationship can you build in a six-minute interview?" she asks.
According to Daniels, the single biggest challenge facing the medical profession is variation among practice patterns for the same type of patient. One recent example, which made headlines, was a finding that many women with breast cancer faced radical mastectomy, even though all the evidence showed similar outcomes when treated with a lasectomy, she says.
The reasons for this variation are threefold, Daniels says. The first is financial. "If you have an MRI, [physicians] will use the MRI [whether] the patient needs it or not." The other two determining factors are where the physicians went to school and where they did their residencies.
Daniels maintains, however, that the increasingly competitive health care environment is presenting opportunities to providers. "Consumer power is giving rise to new opportunities. Con-sumer expectations are going to shape the conduct and the performance of the hospital in the future, and there is a window of opportunity."
Specifically, case managers can leverage the consumer demand for value by applying customer-centric trends to their case management program, she says. And that means aligning the program with the expectations of physicians. "Without the physician, you will not have a patient," Daniels argues, adding that despite the impact of managed care, 60% of admissions come from direct physician referrals. When case managers view physicians as important customers, the benefits that result can include physician loyalty and greater market share. Moreover, if case managers influence the way physicians practice, that ultimately benefits patients as well, she says.
Bringing this about is no easy task, however. She says that it requires a radical shift in thinking about physician motives. Contrary to conventional wisdom, the motive for physicians to work with case managers should not be to reduce the cost per case but rather to save time, give them much sought-after data, and reduce payer denials, Daniels points out. (See charts, below.)
"Together as a team, our primary customer then becomes the patient," says Marianne Ramey, RN, CCM, a partner at PMM. But while that looks good on paper, making it happen on a real-time, everyday basis is another matter, she adds.
Here are some of the tools case managers can employ to facilitate this shift, according to Ramey.
For starters, many case management programs have only a generic mission statement, if they have one at all. Ramey maintains that case management programs need to review their vision for case management and their purpose for being case managers.
Programs then should look at their structure, Ramey says. "What we started with a few years ago might not be adequate anymore. If we truly are going to be able to partner with the physician, something has to change." For example, it is difficult for case managers to act as a real partner to the physician if they have their noses buried in the charts doing utilization review (UR) instead of making rounds with the physician, she says.
In roughly three-quarters of the programs it designs, PMM uses clerical staff to perform contractual UR. "That is what happens until you reach a point where you can reduce your denials enough to renegotiate that onerous contract," Daniels adds.
When it comes to staff reorientation, the old methods may not apply in a customer-centric model, Ramey says. "If you are truly going to be a partner [with] the physician . . . and customer-focused, you must be there for your customer."
In terms of practical application, that requires a shift in behaviors and even appearance. For example, wearing lab coats out on the floor lends a clinical appearance, she says. "Perhaps we need to focus our actions and our behaviors in more of a business alignment and ditch the lab coats."
Perhaps the most fundamental change that must occur is a shift in day-to-day activities, according to Ramey. "We are not going to be able to round with our physicians. We are not going to be able to meet with our patients and families."
"The idealistic model of caring only about the patient is gone," Ramey adds. "Case managers prove their value to the team with numbers, not feelings." Collecting data on avoidable days can demonstrate a measurable outcome and lead to organizational change, she says.
On the other hand, if the organization is not going to do anything with that information, don’t collect it. "Before you throw it out, take a look at what that information might be saying," she points out. The chances are that it points to numerous barriers that exist within your organization. "I am betting that those who get denied-day information can correlate their avoidable days directly with their denied days," she explains. "They can predict when they are going to happen."
According to Daniels, a popular myth is that length of stay is an accurate barometer of effective case management. "Don’t be fooled by it. You must do cost per case."
By decreasing length of stay, providers often cram the same number of services into a shorter period of time, Ramey says. "We got more efficient in providing services that may not have needed to be done in the acute care setting in the first place."
What case managers must do is show a return on health care organizations’ investments. "Organizations put a lot of money in their case management program, and what you want to be able to do is demonstrate a return on that investment," says Daniels. "That will generate even more investment."