Discharge Planning Advisor-Are patients protected when health plans take role in care?
On-site visits, case management standards foster high quality, experts say
What is the fallout for the patient as managed care plans play a role in directing the health care of their members, either through their own case managers or by outsourcing the function to another organization?
With many health plans losing money and targeting hospital length of stay more aggressively than ever, are the patient's rights being protected? Can health plan delegates remain neutral and unbiased in their decisions about a member's care?
The process varies from company to company, but in the best of worlds, it works very well, says Peter Moran, RN, MS, CCM, Cm, president of the Case Management Society of New England and staff nurse case manager for Harvard Pilgrim Healthcare in Portland, ME. "The good thing is, it brings in somebody who knows the patient. If I follow my members, know them in a home situation, know their past history, this can be addressed before they arrive at the hospital."
With short lengths of stay, this advance knowledge is invaluable, Moran points out. "In my situation, I work with the hospital discharge planner and we collaborate. I explain to them what the insurance benefits are — does the patient have home care, skilled nursing benefits? — and that I intend to follow them across the continuum."
Two cornerstones of his own practice, Moran says, are on-site visits and use of a professional case management model. "I won't say there aren't sometimes disagreements, but then you come up with a compromise that meets everyone's needs."
Handling cases over the telephone, he adds, allows health plan representatives to depersonalize patients, to think of them as "the total hip in Room 14 or the hysterectomy in Room 3."
Although case management is "the current buzz term" and everyone wants to have it, Moran says, "the question is to ask them what they really do. Some people will call themselves case managers and will sit on the phone, get the information that Mary Jones is going into the hospital and say, 'Fine, two-day length of stay, good-bye.' Because there's not a relationship there, it's easier to deny because you don't have the whole picture."
If health plan representatives are calling themselves case managers but are using a strict utilization review model, they're looking at getting the patient out of the hospital, not at the continuum of care, he notes. "There are a lot of decisions being driven by money in certain organizations."
The best course of action when dealing with health plan representatives is to move away from the interpersonal and resolve conflicts at a higher level of the organization, suggests Lois Pabst, RN, MBA, CNAA, A-CCC, director of care management for Eastern Connecticut Health Network in Manchester.
"When you get into a situation where the [health plan's] medical director is directing the utilization review nurse to do certain things, don't get into a battle with her," says Pabst. "There is a lot of change in management within many companies. While we interact with the review nurse, a change in the medical director or the advisory committee results in the changes we see on the front line."
The most common problem she faces, for example, is when a health plan begins micromanaging a patient's hospital stay as opposed to evaluating the appropriateness of the stay, Pabst adds. When that occurs, she says, "we request a meeting of the plan's medical director and supervisor of review nurses, myself, and our physician advisor to discuss the implications of the change in behavior. We are generally able to come to some agreement."
Her organization has been fortunate in its dealings with health plan reviewers, she notes, probably because it took a proactive stance early on. "I've been in this role a long time prior to managed care, and as it became more pervasive, we continued to establish relationships with insurance plans," Pabst says. "When we had [reviewers] who did not appear to be well-qualified, we would interact at the company level to indicate our frustrations. This raised the awareness on the part of [managed care] companies for qualified people to do their reviews."
Providers in other areas of the country are not as lucky in their dealings with health plans, Pabst notes, a point that is underscored by Sandra Lowery, RN, BSN, CRRN, CCM, president-elect of the Little Rock, AR-based Case Management Society of America.
"[Providers] are being asked to provide utilization reviews on patients in unprecedented numbers — often on up to 100% of their patients," says Lowery, who is president of CCMI Associates, a case management consulting firm in Francestown, NH. "Some hospital case managers are being asked for daily utilization review of their patients. If there are 30 patients on a floor, that leaves little time for other responsibilities."
There is almost always someone from the health plan overseeing utilization of benefits, but to have someone fill the case management role is far less common, Lowery notes. "That happens if [the case] meets a trigger point, a severity indicator, if the health plan has case managers, and if they have qualified case managers."
There usually are selection criteria for a case manager rather than a utilization reviewer to work on a case, she adds, and the decision is clearly based on financial risks.
Patients and families — as well as the employers who select health plans — need to be educated about the benefits of having a case manager assisting them and about how well various health plans serve the patient's interests, Lowery says. (See related story, p. 9.)
Many providers have merged utilization review and discharge planning under the umbrella of case management, she points out, and payers have done the same thing. "Utilization review professionals and case managers and discharge planners have different skill sets, but utilization review nurses are increasingly required or requested to perform case management."
Although such an approach may reduce fragmentation, "it's not good if the person is not qualified to do it. They may or may not have interviewed for the new position."
Changing plans fosters short-term approach
One of the ways health plans differ is in whether they look at coverage over the long haul or in the short term, notes Pabst. "Some are very short-term, bottom-line-focused. There are others who appear to manage over the long term, to improve the health of the members."
In the past, Moran points out, employers stayed with insurance plans for a long time. "Now a lot of companies shop around and people are forced to change plans," he says, which tends to foster a short-term approach to health care spending. "Some health plans may not see the importance of spending up front and saving later. If a person has multiple sclerosis and is now mobile, for example, a lot of effort can go into prevention."
On the other hand, he says, "Where do you draw the line?" It's a given that hospital discharge planners and case managers are under pressure, Moran acknowledges, but he says they often don't understand the insurance perspective. Restrictions are often driven by the employer, Moran adds, with high copayments and deducti bles and limited catastrophic coverage.
"If I'm a nurse in an oncology research unit," he continues, "and have a patient dying and a question about a new experimental treatment, I might say, 'The insurance companies just want people to die. They're not willing to pay for this.'"
In reality, experimental treatments may be an exclusion in the member's policy, Moran points out.
"Maybe we should cover it, but then where do you draw the line?" Moran says. "There's always another one out there, so what don't you cover? The underlying belief system is that health care is a right, but that's not written out anywhere. People are not willing to pay more taxes, and employers can't afford to pay premiums. These are social issues. The industry is being run more and more as a business."
The question then becomes, "What can we do to maximize the benefit so people get the appropriate care in the appropriate setting at the appropriate time?" Moran asks, suggesting, "If the insurance case manager, the hospital discharge planner, and the home care and rehab managers meet in forums outside their jobs and get to know each other, they understand where the other person is coming from."
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