One Health Care Strategy is Just Not Enough

Case management looks at the individual; disease management looks at the population. Together they address the full spectrum of health care cost and quality issues.

By Diane L. Huber, PhD, RN, FAAN, CNAA, BC

When any business expense spirals upward, smart companies take a comprehensive approach to restoring control. They understand that a narrow strategy won't solve a broad-based problem. This certainly holds true for health benefits, as waves of ever more sophisticated and expensive care crash on the shore of an aging workforce. Two strategies stand out as important components of a comprehensive employer response.

In the first, employers make sure that employees who are ill or injured have access to the right treatment in a timely and cost effective manner. This is the essence of case management, which seeks to control costs and allocate resources while ensuring that patients receive quality care that will return them to wellness and productivity.

The second strategy identifies and assesses common health issues in an employee population. Are there chronic illnesses or injuries in the workplace? Is a large segment of employees at risk for age-related illnesses? Are there high-risk pregnancies, diabetes or obesity? What processes, employee education and self-care programs would address and prevent these health concerns? This is the essence of disease management.

Complementary, yet distinct, case management and disease management are powerful tools for controlling costs and promoting health. Both can be applied to various benefit programs, covering job-related injuries and illnesses (via workers' comp) as well as non-occupational conditions (through health insurance and long-term disability).

Importantly, these strategies can be implemented by virtually all employers, from large corporations with case and disease managers on staff to smaller firms that contract with consultants and outside providers. To be most effective, however, companies must understand the distinctions of each field of practice.

Case and disease management defined

The Case Management Society of America (CMSA) is a professional organization that sets standards for the field it defines as "a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes."

The Disease Management Association of America (DMAA), a non-profit membership organization, defines its field as "a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant."

Together, case and disease management address today's medical needs and anticipate tomorrow's health issues. They are "very complementary approaches," observes Bruce Steffens, MD, Senior Vice President and Chief Medical Officer for John Deere Health Plan, Inc., a managed care organization. "At our company, the head of disease management and the head of case management are about 20 feet away from each other. We see them as the left arm and the right arm."

"Case management has its origins in the management of catastrophic injuries and illnesses, such as spinal cord injuries, head injuries and amputations," adds Michael B. Garrett, MS, CCM, Vice President, State and Private Programs, for Qualis Health, a quality improvement organization headquartered in Seattle. "Disease management allows the principles of case management to be applied to chronic conditions and illnesses by working with patients and families."

Each field takes a distinct approach to employee health: Case management looks at the individual, while disease management focuses on populations.

Shared responsibility

Attempts to rein in health care expenses may put employers at odds with their employees, who fear cutbacks in the quality or availability of services. Communication and coordination — essential to defusing such conflicts — are core components of both case and disease management. They foster an environment of "shared responsibility — and if employees are to continue enjoying the peace of mind that comes with health care coverage, they need to understand their role," states a recent Watson Wyatt study titled "Creating Informed Health Care Consumers: A Communication Challenge."

"Whether managing their asthma more effectively to avoid costly ER visits, avoiding unnecessary duplicate coverage and tests, or scheduling an annual health exam to screen for disease in the early stages, each person must do their part to keep health care affordable for themselves and their employers," the study added.

The responsibility flows both ways, according to Patricia McCollom, principal of Management Consulting and Rehabilitation Services Inc., a case management company based in Iowa. "Case management carries with it a great deal of accountability and responsibility, she points out. "The employer, indeed, has accountability and responsibility to the people who are injured at work and to those who are covered under its group health plans."

Putting dual strategies into action

Steffen advocates tapping into "the potential to integrate case management and disease management." On a practical level, case management promotes effective use of health care resources, providing advocacy and coordination of care, whether a person was injured at work or suffering from a chronic illness.

These days, case managers are dealing with caseloads that are increasingly complex and demanding. One reason for that is a powerful dynamic in the workplace: the aging of the population. The Bureau of Labor Statistics estimates that by 2010, the working population aged 25 to 64 will increase by 12.8 million, with almost 90 percent of the increase occurring among persons aged 55 to 64.

"There is a reaction among employers that ‘this is getting awfully expensive here,' particularly as the workforce ages and the baby boomers turn 50 and 55," Steffens notes. "It's not unique to any one employer. All employers have more 50-year-olds than they used to, and there are some higher cost trends. Now looking forward, as the baby boomers turn 55 and 60, companies are asking themselves what can they do to prevent further health problems."

That's a situation that's tailor made for disease management, which aims to identify, manage and prevent the specific diseases or conditions that occur within a population. An employer, for example, may have a significant number of employees who have asthma or diabetes. Perhaps there is a common work-related condition such as repetitive stress injury. Through patient education and self-care, with a heavy reliance on evidenced-based practice guidelines, disease management can provide the earliest possible intervention to control and prevent escalation of these health problems.

For one employer, the focus of a disease management program was smoking cessation. It offered incentives — including trips to Hawaii — to those who quit and did not smoke for 12 months. If they relapsed within a year after taking the trip, they had to pay back the cost.

"The message was very clear," McCollom recalls. "We as the employer are doing what we can to promote your health. You as the individual have a responsibility to yourself. The company facilitated zero-smoking from a positive perspective versus a punitive perspective."

Through education and promotion of self-care, disease management can help create a workforce that is healthier or is stabilized while having a chronic condition. That translates into a competitive productivity advantage for employers.

Where to start?

Companies that want to utilize case management and disease management strategies should start with the resources at hand. Small companies may be able to team up members of their staff with people from their insurance providers or a hospital/care provider network. Consultants and other outside professionals can also help companies to design and implement case and/or disease management strategies. Larger employers may have case or disease managers on staff.

Once the resources are identified, employee demographics and current health claims will help identify likely targets. "Companies should be able to take a look at their health claims and get some kind of sense of where the money is being spent. There is typically a small group of people who are quite sick and generate the largest portion of charges," says Steffens. "Likewise, there is usually a small group of diseases that account for most of the costs. We find about 80 percent of the costs in 20 percent of the members, most of them due to chronic diseases."

To be most effective, case management and disease management require a deliberate and collaborative approach, involving the employer, the employee, the employee's family and caregivers, treating physicians, and other care providers such as physical or occupational therapists.

"The No.1 thing to understand is that we are all in this together," McCollom concludes. "The days of the employer directing what shall be in terms of health care are limited. The greatest gains are made by employers who take a collaborative approach to health."

Diane Huber is a professor at the University of Iowa College of Nursing, teaching case management courses. She is also an investigator at the UI Center for Addictions Research, Institute for Strengthening Communities, and chair of the Commission for Case Manager Certification (CCMC), which has awarded the certified case manager credential to more than 26,000 professionals since 1992. The CCMC is the only certifying body for case management professionals accredited by the National Commission for Certifying Agencies.

Resources:

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

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

Disease Management Association of Americahttp://www.dmaa.org

More Business & Health Articles About This Topic:

Why We Can't Wait to Implement Disease Management (Oct 15, 2003)

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

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

Disease Management Comes of Age, Not a Moment too Soon (June 19, 2002)

Diane Huber. One Health Care Strategy is Just Not Enough.

Business and Health

Nov. 7, 2003;21.