Health care system offers challenges, opportunities
New CMSA president working to spread the word
One of the biggest challenges facing case managers today is educating the consumer and other health care providers about what case managers do and the value they bring to the table, says Jeff Frater, RN, BSN, CCM, new president for the Case Management Society of America (CMSA).
As president, Frater wants to work to develop a definition of case management and to spread the word about the profession.
"One of the greatest challenges to case managers as a whole is the role definition and the protection of the title. In the nursing world, someone who calls themselves a nurse has the license to demonstrate it. Case managers don't have the same kind of protection. People can call themselves a case manager and not even be aware that there are standards of practice," Frater says.
For instance, he points out, utilization management is not consistent with the definition of case management contained in CMSA's standards of practice.
"Most people who do case management at times perform utilization management and utilization review but if that's all you're doing, you shouldn't be calling yourself a case manager," he says.
CMSA is in the midst of a project to come up with clear definitions of all the titles and roles in the profession in collaboration with partner organizations, such as the National Association of Social Workers and URAC, Frater says.
"We need to define the difference between case management and disease management, between care coordination and utilization review. Many case managers that I have talked to spend more time on utilization management than case management. Their job title says 'case manager' but their role and function is more utilization management and discharge planning," he adds.
There is an opportunity for CMSA to take a leadership role in defining the roles and functions connected with the title of case management as well as educating people both inside and outside the health care field about the differences, he says.
In today's increasingly complex health care arena, case managers have more opportunities than ever before to advocate for and assist their clients in making informed health care decisions, Frater says.
Consumer-directed health plans are a case in point, he adds.
"These health plans put the burden of decision making on the patients, who often are poorly equipped to make intelligent decisions. There is a real opportunity for case managers to guide individual consumers through the health care system and help them make informed choices," Frater says.
A mechanism that reimburses for case management services would be invaluable in expanding the role of case management to coordinate care for people in a variety of settings and help consumers navigate the complex health care maze, he adds.
CMSA is working to develop a CPT coding initiative for case management services that would provide reimbursement for telephonic and face-to-face encounters by case managers, he says.
The Centers for Medicare and Medicaid Services (CMS) has given the "N" status to three CPT codes for non-physician telephone assessment and management services by non-physician-qualified health care professionals.
"An 'N' status means CMS won't be paying for the service but they have assigned relative value units to these CPT codes, which sets the stage for health plans and others to determine reimbursement for these services," he says.
CMSA is urging CMS to provide reimbursement for the services.
"We are working on a strategic initiative to get payment for case management services, whether it's through Medicare, commercial insurers, or by having patients pay for it out of the health care savings account," he says.
The most likely scenario in which case management services could be reimbursed by CMS or commercial payers would be in a physician office setting, he says. This could be invaluable in pay-for-performance initiatives.
"A nurse case manager can help the physician make sure their patients with chronic conditions are receiving the routine care they need. The new CPT codes would give the physician offices a way to get reimbursement by having case managers work in alignment with them to improve the quality of care," he says.
The CPT codes would also allow case managers in independent practice to be reimbursed for their services, he adds.
This fall, CMSA is rolling out a new web site that will include content to help people not in the case management profession understand what case managers do.
"We will have a portal for members, a portal for employers, a portal for public policy makers, and a portal for consumers," he says.
CMSA continues to support case managers by developing tools that help facilitate their every day work, Frater says.
"Many case managers, regardless of practice setting, struggle to find tools and resources that will help them do their jobs. In my work as a trainer, I find that case managers get most excited about tools that will help them perform a thorough assessment and develop evidence-based treatment plans," Frater says.
The Case Management Adherence Guidelines, developed by CMSA, are assessment and interventional tools for measuring adherence, Frater says.
"This is a tool that can help bolster what is missing and to reduce the barriers in that patient's adherence," he says.
One of the biggest challenges facing case managers today is educating the consumer and other health care providers about what case managers do and the value they bring to the table, says Jeff Frater, RN, BSN, CCM, new president for the Case Management Society of America (CMSA).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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