Try this best practice approach to HIV care
CM leads to success in HIV/AIDS managed care
Case managers play an essential role in helping payers and providers control the high costs of managing the HIV/AIDS population in a managed care environment. With the estimated lifetime average costs of HIV-related care running about $225,000 in 1994, payers and providers both began looking for appropriate measures to manage runaway costs of treating the HIV/AIDS population.
And case management topped a list of successful strategies for managing HIV patients in managed care settings identified in "Research Report: HIV/AIDS Managed Care," a recently released report by Seattle-based Milliman & Robertson. "There are three aspects of managed care that offer a solid way of managing this population," notes Bruce Pyenson, FSA, MAAA, a principal with Milliman & Robertson's New York City office and a co-author of the report. "Those aspects are financial, infrastructure, and clinical."
"Case management is an important part of the infrastructure that provides coordination among the health disciplines, streamlines communication, and arranges for specialty services," adds Sherrie Dulworth, BSN, a health management consultants with Milliman & Robertson's New York City office and the report's other co-author. "Case management duties vary according to the specific delivery model and insurance benefits. Transportation arrangements for medical appointments and social support services are pressing needs for the Medicaid population, while return-to-work assistance tends to be more important for commercial members."
"It's important to have more than a case management model," adds Dulworth. Common case management functions Dulworth and Pyenson identified through their research of best managed care practices include:
· coordinating community-based services, such as food preparation assistance;
· assessing the social support system;
· arranging financial and housing assistance;
· arranging respite care for primary caregivers;
· arranging homemaker care, such as laundry help;
· finding vocational assistance or job counseling;
· educating patients on lifestyle issues and wellness habits.
"One of the strengths of managed care directly related to strong case management is helping to increase efficiencies. This includes identifying potential delays in care and eliminating barriers," says Dulworth.
Three steps to financial planning
Case management is an important strategy for managed care of HIV/AIDS patients, but before planning a care coordination model, payers must understand clearly what their current costs are for this population, Pyenson says. "This means creating an actuarial model considering reimbursement levels. The goal from a financial standpoint is to deliver better care at the same or lower cost. Before you can do that, you have to know where you are currently."
The second step payers should take in their financial planning of managed care products for HIV/AIDS patients is to evaluate potential vendors against the managed care organizations' current network, he says. "There's not much point in subcapitating to outside vendors if those vendors can't do a better job than you're already doing."
Questions Pyenson recommends payers consider before using specialty vendors for HIV/ AIDS care include these:
· Can the vendor manage all aspects of care?
· What aspects of care can't our current providers cover?
· What volume of patients can the vendor realistically handle?
After putting together steps one and two, payers can then initiate step three, which is drafting contracts that establish clearly defined risk sharing arrangement and include stop/loss protection, Pyenson says.
Building blocks for success
Financial planning is an essential starting place, but successfully caring for HIV/AIDS patients in managed care requires a strong infrastructure, say Dulworth and Pyenson. In their research, the team identified the following components of a successful infrastructure:
· management information systems;
· quality management;
· provider selection;
· medical management;
· case management.
"Managed care doesn't work without sophisticated information systems. One of the most common mistakes providers make in HIV/AIDS managed care is to fail to compare actual outcomes to the projected budget on a monthly basis," Pyenson notes. "Actual costs come in higher than budget, but because they wait until the end of the contract period to compare costs, they've lost money, and it's too late. If comparisons are made monthly, immediate action can be taken to control costs."
From both the payer and provider perspective, appropriate provider selection means that HIV specialty providers are available on a 24-hour, seven-days-a-week basis to manage care of the HIV/AIDS population, notes Dulworth. "You must make sure you have the depth of coverage necessary for your particular HIV population. For example, if your contract covers children, do you have the necessary network specialists to handle the special needs of a pediatric population?
"You may have the best acute care providers in town, but do you have the necessary sophisticated home care services necessary for HIV/ AIDS management, such as infusion therapy providers?" asks Dulworth. Other provider selection issues she suggests payers consider when developing managed care products for HIV/AIDS populations include:
· Do you have providers who can handle your the entire geographic area covered by your contract?
· Do you have an adequate pharmacy network?
· Does your pharmacy provide tools to manage and monitor patient compliance?
· Does your HIV/AIDS population require substance abuse counselors?
"You must understand your member population and make sure you have the necessary depth and breadth in your providers to provide adequate coverage," Dulworth cautions. "You have to perform an assessment of your network strengths and weaknesses and develop an unbiased picture of your managed care readiness for an HIV/AIDS population."
Dulworth and Pyenson's research confirms that it pays to use specialists for HIV/AIDS managed care delivery. "A provider who treats a high volume of AIDS patients is most likely to remain current with the most recently published clinical guidelines," Dulworth says. "What's right for HIV/AIDS care today will change tomorrow. You must make certain that the providers you choose follow what is being published by current experts in the field."
HIV/AIDS case managers also should be experts in the field, she notes. "This doesn't mean that if you are an HIV/AIDS case manager for a large payer you can't manage other types of cases. It does mean that to be an HIV/AIDS case manager, you should have a certain baseline of knowledge and experience."
Politics rears its head
Case managers can't overlook the politics of HIV care within a managed care organization, Pyenson says. "If you have a scattering of AIDS patients assigned to a variety of primary care physicians, it may cause some primary care physicians to be under-reimbursed on a capitated basis. That's normal unless you adjust capitated rates to adequately reimburse for AIDS patients."
It may make more sense politically to concentrate those patients with certain physicians and adjust reimbursements accordingly, he notes. "This type of risk adjustment may help you solve some provider complaints. Although many providers dealing with HIV/AIDS patients are in a nonprofit mode, it's still important to attempt a more equitable distribution of available funds."
Gear up with more 'horsepower'
However, Pyenson and Dulworth's literature review and their analysis of successful HIV/ AIDS managed care plans nationwide indicate that success continually comes back to a strong case management program. "In the best HIV/ AIDS managed care plans, case management becomes less of a vendor and more of a leader. Case management becomes an integral part of the organization," Dulworth says.
"In fact, one weakness we find in many managed care plans is that the plans look at a combination of case management and utilization management as supporting ill-defined quality outcomes and ignoring efficiency," Pyenson adds. "Many times, we found case managers and utilization managers in the role of justifying medical practice and rationalizing inefficient treatments. To succeed, payers and providers must empower the case management function."
To illustrate the need for strong case man agement programs, Pyenson likes to use an automotive analogy. "To go from zero to 60 miles per hour in a given number of seconds, you need a certain horsepower and gear ratios," he says.
"If you want your organization to reduce inpatient days per thousand HIV/AIDS members, there are certain case management and utilization management policies and procedures that must be in place."
[Editor's note: If you are interested in more information or a copy of the research report, contact Dulworth at (212) 279-7166.] n
· Nov. 11-14. 10th Medical Case Management Convention. "Case Management: Expanding the Vision and Thriving in the 21st Century." Pennsylvania Convention Center in Philadelphia. Sponsored by Mosby Year Book in St. Louis, The Case Manager magazine, and the Case Manage ment Society of America (CMSA) in Little Rock, AR. Cost is $499 for non-CMSA members and $569 for members. Call (760) 431-9797. To register, mail your payment to Mosby/MCMC, P.O. Box 2789, Carlsbad, CA 92018-2789. Fax: (760) 431-8135. Or visit the Web: http://www.mosby.com/MCMC.
· Dec. 10-13. Fourth International Confer ence on Long Term Care Case Management. "Care/Case Management at the Crossroads: Which Way To Quality?" Sheraton San Diego Hotel and Marina. Sponsored by the American Society on Aging (ASA) in San Francisco. Cost is $320 for ASA members and $370 for nonmembers; $25 continuing education fee. Contact ASA, 833 Market St., Suite 511, San Francisco, CA 94103-1824. Telephone: (800) 537-9728. Fax: (415) 974-0300. Web: www.asaging.org.
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