Making the Case

Case Management isn't just for the catastrophic. This cost-containing service has a broader appeal to employers looking to reduce health care and disability costs.

By Michael Garrett, MS, CCM, Commissioner, Commission for Case Manager Certification (CCMC)

While many employers may associate case management with such catastrophic situations as a severely ill or critically injured employee, these services have a far broader application — and can potentially reap greater savings over a wider employee population.

Granted, for catastrophic illness or injuries, case management can significantly reduce health care and disability costs. But at most companies the population of catastrophically ill or injured employees, thankfully, is a limited one. A far larger employee population is found in the individuals who suffer from chronic conditions that result in absence from work, short- or long-term disability, and frequent use of medical benefits. While the cost savings for each case may not be dramatic, when case management is applied to this broader population, the savings can be significant. There may also be a significant improvement in health status and functional capabilities.

All employers, whether they are self-insured or they purchase coverage, can utilize case management to help address spiraling health care and insurance costs for employees and their dependents with catastrophic and chronic conditions. To receive the full potential benefit of case management, employers must become more informed purchasers when it comes to selecting case management services for any insurance coverage, regardless of funding arrangement (i.e., fully insured or self-funded).

This article hopes to shed some light on case management by offering a rundown on how case management can fit into your business, as well as a checklist for employers.

Workers' compensation

Handling workers' compensation cases is where modern case management began. Traditionally this involved employees who were severely injured (such as crushing falls, head injury or spinal cord injury) and who were placed on temporary total disability (TTD). Case managers were assigned to help coordinate the medical care and treatment as the injured worker progressed through the care delivery system. Once the person was treated medically, the next concern was the individual's employability and return to work. This was where vocational case management came in.

The effectiveness of case management is influenced by the timing of referrals to case management services in workers' compensation. Therefore, employers need to inquire about how and when cases are referred for case management services. Early intervention with case management can help employers to control time loss costs as well as medical costs. Typically, a blend of vocational and medical case management services can address both aspects of cases.

Long-term disability

Long-term disability has many of the same issues as worker's compensation. When an employee is off work for an extended period of time due to illness or injury, case management is an integral part of assessing that individual's rehabilitative needs, employability, and returning him or her to work in some capacity.

Employers that purchase worker's compensation or disability insurance shouldn't just assume that case management is automatically used. Rather, employers should know if the worker's compensation or disability insurance carrier has case managers. If so, are they non-clinical professionals who adjudicate claims, or are they clinical professionals (such as nurses) who can assess the medical treatment? Further, what triggers case management? Is it the severity of the illness or injury, the duration of the disability or the total expected cost of the claim?

Case management is essential in complex cases that need not only medical attention but psychosocial and occupational services as well. For example, with a head injury the medical focus is on physical conditions such as swelling of the brain and functional impairment. Head injuries, however, can also result in psychosocial issues, such as difficulty communicating or behavioral changes. There will likely be vocational issues depending upon the individual's competencies as a result of the injury. A case manager with a clinical background can work with the claims manager to ensure that all the medical and rehabilitative needs of the individual are being addressed.

Group health/medical insurance

For group health/medical insurance, employers need to inquire whether their insurance carrier or HMO (or third-party administrator in the case of self-insured employers) provides case management. If so, are the case managers clinical or non-clinical professionals? What percentage of cases goes to case management, and what are the triggers (i.e. diagnoses, cost of claim, etc.)?

While case management for group health has typically been reserved for the most acute cases — such as oncology, organ transplants or neonatal — the benefits can be extended to a large population through disease management. Case management can monitor the treatment of employees who suffer chronic conditions — such as asthma, diabetes or congestive heart failure — to ensure that employees have access to the right medical resources to maximize their health and status.

An employer cannot dictate how a medical provider such as a hospital or clinic delivers case management services. However, the employer can inquire how well case managers at the insurance carrier or third-party administrator interface with their counterparts at the care provider. Good interaction between the payer and provider will enhance the effectiveness of case management services.

Whether self-funded or purchased, group health/medical coverage can be enhanced with disease management. As stated in "One Health Care Strategy Is Just Not Enough" (Business & Health, Nov. 7, 2003), case management and disease management are powerful tools for controlling costs and promoting health. Through disease management, employees with chronic conditions benefit from early identification, structured clinical guidelines, patient education, and ongoing monitoring of adherence to care/treatment plans. Once again, employers should inquire as to whether their carriers or third-party administrators offer disease management, which should have case management as a core component.

Self-Insured employers

Assessing the effectiveness of case management, self-insured employers must look closely at how and when these services are being used. For large employers that have case managers on staff, are these services integrated across the spectrum of benefits, or are they limited to, say, workers' compensation cases? Integrated programs allow case management to be deployed for individuals who need these services, regardless of whether the illness or injury is job-related.

If a self-insured employer contracts with a case management organization or third-party administrator for case management services, they can still drive the program. The key, however, is to be an informed purchaser. Employers should know the professional backgrounds of the contracted case managers. Are they certified professionals? Is the case management firm accredited, such as by URAC or NCQA? What are the timeframes and the content of the care plans that case managers develop? How and when are all parties notified when the case is closed?

Another consideration for employers is the reporting of outcomes. This includes the economic/financial impact that will allow an employer to determine the return on investment for these services. Another issue is the clinical or functional outcome for employees who receive these services. How quickly and effectively are these individuals returned to health and productivity? Finally, what is the satisfaction or perception of the patients and families who utilize these services?

With escalating health care costs and concerns about a keeping an aging workforce healthy and productive, case management will play an important role from workers' compensation to disability insurance to medical insurance. To be most effective, however, employers must know the right questions to ask and be able to assess the answers.

For more information or to obtain an application for the CCM, contact the Commission for Case Manager Certification at (847) 818-0292 or visit the CCMC Web site at www.ccmcertification.org .

Michael Garrett, MS, CCM, is a Commissioner for the Commission for Case Manager Certification (CCMC), which has awarded the certified case manager (CCM) credential to more than 26,000 case management professionals since 1992. The CCMC is the only certifying body for case management professionals accredited by the National Commission for Certifying Agencies. URAC also has determined that the CCM credential is a recognized case management certification. Mr. Garrett is also vice president of business development for Qualis Health of Seattle, a private, nonprofit organization that offers programs and services to improve the quality of health care delivery and health outcomes.

Employers' Case Management Checklist

Employers today need to be able to assess the quality of case management services to determine the value they are receiving for the money spent. Typically, in looking at quality, three domains are reviewed: structure, process and outcomes. Asking questions related to each of these areas will help employers assess the quality of case management services.

Structure:

Process:

Outcomes:

More Business & Health Articles On This Topic:

One Health Care Strategy Is Just Not Enough ( Nov. 7, 2003)

Managing Large Claims Down to Size (Aug.1, 2003)

Case Management: You Really Do Get What You Pay For (Oct. 3, 2002)

Resource Links:

Case Management Society of Americahttp://www.cmsa.org
or (847) 818-0292

Commission for Case Manager Certificationhttp://www.ccmcertification.org

Michael Garrett. Making the Case.

Business and Health

Mar. 17, 2004;22.