UM companies focus on case management
CM fits high-return’ model
There may be good news on the job market front for case managers, according to a new study by URAC, the American Accreditation HealthCare Commission based in Washington, DC.
The survey of companies registered to provide utilization management showed that they are increasing their use of case management and disease management to complement utilization management.
The study, "Trends and Practice in Medical Management: 2001 Industry Profile," addressed the evolution of utilization management and how it relates to case management and disease management.
The companies surveyed reported that they are looking for better ways to do business. Their strategies include cutting down on pre-certifications, concentrating on procedures most likely to be overused or abused, or identifying groups or individual providers who typically fall outside of utilization norms.
They’re taking the staff and financial resources previously used for pre-certification and using them for case management and disease management for patients with the need for intensive interventions.
"They’re using utilization management as an early warning system to get patients who need it into case management. There’s still the age-old challenge of proving the return in outcomes for case management. But a lot of companies are demonstrating that they believe that case management can deliver better outcomes by coordinating services and helping providers stick with evidence-based practices," says Liza Greenberg, RN, MPH, vice president of research at URAC.
Although utilization management is changing, it’s not likely to be eliminated completely in the near future, the researchers concluded. Instead, companies view utilization management as having an important role in containing costs.
However, medical management organizations see the need to focus on patients who need a higher intensity of care and those who have difficulty navigating the complex health care system. They are looking at predictive modeling as a way to identify future high-use patients.
The companies are using case management and disease management to improve compliance with evidence-based care recommendations and to improve patient outcomes says Michael Harwick, MD, a consultant to the study.
"They are building a high-return model by increasing case management and discharge planning and reducing emphasis on prior authorizations. An intentional byproduct of this strategy is reduced administrative burden for physicians and, the companies hope, better relationships with physicians," Harwick adds.
Staffing needs are changing as the companies shift their emphasis from direct utilization management to case management.
"Our study shows that companies still view utilization management as an important tool for evaluating medical necessity. However, companies are now using utilization management as a gateway. They are reviewing fewer procedures but looking more closely at each encounter to identify opportunities to improve and coordinate care more effectively," says Garry Carneal, JD, MA, president and chief executive officer of URAC.
The study may indicate an increase in demand for the services of case managers, but other factors could affect the job market in the immediate future, Greenberg points out.
"One sort of confounding factor is that the economy is affecting people covered by health care plans. Although companies are increasingly using case management, if their enrollment goes down, there still may be employment contractions," she adds.
The real implication for case managers in the study is recognizing trends in the industry, Greenberg says. For instance, the URAC investigators heard repeatedly that companies are converting to electronic ways of communicating because of the increase in efficiency.
Health education and health information through the telephone or Internet are increasing as components of utilization management, case management, and disease management programs, or as independent components.
For instance, many health care organizations have nurses who answer telephone questions about nonlife-threatening conditions 24 hours a day. Many companies offer health education on the Internet, including health risk assessment.
The companies are focusing on evidence-based practices as the most effective and efficient way to treat patients.
Patients are able to make more decisions about their benefits and their providers and to share in the financial risk.
Researchers surveyed companies registered to provide utilization management in the state of Illinois. "There is no comprehensive list of utilization management companies. We used Illinois because the companies are required to register," Greenberg says.
The study included an Internet-based questionnaire, focus groups, and interviews of medical management leaders, site visits to several companies, and a search of peer-reviewed literature for industry trends and practices.
Participants included 120 different companies representing a cross section of companies providing medical management services. Survey respondents included HMOs (23%), PPOs (36%), stand- alone medical management companies (39%), insurance carriers (20%), and others.
"URAC’s findings suggest that medical management has the potential to influence cost and quality within the health care system. The success of medical management’s evolution may be dependent upon the ability of companies to capture and use data to develop targeted, integrated programs and to influence providers in a collaborative, educational manner," the researchers wrote.
Material you may need during the accreditation site visit
- A copy of the application for accreditation
- Copies of other information provided to URAC
- Committee minutes for each committee relevant to the standards
- Files that may be selected for examination, including complaints, appeals, credentialing, and employee quality initiatives
- Policies, procedures, and guidelines available to staff
- Training materials for new employees
- Analyses, reports, and data from quality assessments
- Delegated contracts and reports between delegated entities and the program
Materials to include with application
- Application cover sheet
- Billing worksheet and payment
- Signed representations by the applicant
- Corporate information, including attestation of compliance with applicable state and federal laws
- Site-specific information
- Signed multi- or mega-site representations if applicable
- Documentation as evidence of compliance with each URAC standard
- Articles of incorporation, including organizational charts.
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