You need relationship to deal effectively with managed care managers
Build network with MCO counterparts
As if hospital-based case managers didn’t have enough responsibilities to handle, many are increasingly having to take the lead in dealing with managed care companies. And how well you relate to your managed care colleagues could spell the difference between a cooperative or antagonistic relationship between your hospital and the managed care companies with which it contracts.
"While they were normally doing straightforward discharge planning, hospital-based case managers now have the added responsibility of having to keep in mind, for each of the HMOs they are dealing with, which of the home health agencies, which of the skilled nursing facilities, and so on, are in their network," says Paul Reich, MD, chief medical officer and consultant with the Scheur Management Group in Newton, MA.
Reich says the worst thing hospital case managers could do as far as the managed care company is concerned is to send the patient to a place where the MCO doesn’t have a contract, because then the patient would have to pay full charges. "That has created problems for hospital-based case managers," Reich says.
He notes that managed care companies increasingly are setting up case management programs, particularly in Medicare, to manage their high-risk, high-cost patients through the whole continuum of care — while they’re in the hospital, when they come home, if they go to a skilled nursing facility, and even as outpatients.
Because the managed care case managers want to manage over the whole continuum of care, they want to work with their hospital counterparts. "But hospital case managers might perceive their efforts as the managed care case managers wanting to take over the case," says Reich, who has experience setting up case management programs for MCOs "On one hand, having someone share in the work relieves the work load, but on the other hand, it can be seen as a move to take one’s job away." He says that interface has to be managed very carefully.
Bridging the divide
His advice: "Get to know managed care case managers personally. Visit with them so they are not just voices on the other end of the telephone. Let them know you are there for them when they need advice on a particularly troublesome problem." He says both types of case managers have to realize they are in the same business of trying to do the best thing for the patient.
Toni Cesta, PhD, RN, director of case management at Saint Vincents Hospital and Medical Center in New York City, would go one step further: "One of the ways we build bridges with our managed care case managers is having offices for them on-site in our hospital. That way, they interact with the hospital case managers on a daily basis and work proactively with them. We make them a part of our team." Cesta says by having those on-site offices, case managers have been able to manage and reduce the number of insurance denials they receive from on-site reviewers.
"Some opponents of this system think that if these people are on-site, they’ll be looking in the charts and find more things to deny," says Cesta. "We’ve found the opposite. They see how sick some patients really are, so it works to our advantage."
Lawrence F. Strassner, MS, RN, of Ernst and Young in Philadelphia, adds, "Often there is some skepticism by hospital providers — physicians and case managers — regarding the overall focus of the managed care case managers. Typically, they have been viewed as focused only on UR [utilization review] and less on clinical care coordination. [The managed care case manager] has also been seen as the person who is recommending a denial day or denial of a planned service." Strassner says managed care case managers are often generalist-focused rather than disease specialists, and that has led to some skepticism on the part of the hospital providers.
"As managed care companies are taking a more active role in managing and coordinating care, traditional UR must become less the focus, with more of an integrated approach to care coordination that includes utilization management," Strassner explains. "The focus of the managed care case manager — particularly with risk patients — is more on care coordination across the continuum." So the hospital case manager is just one piece of the continuum, but often the most costly piece of care. Strassner says it is essential that the managed care case manager and hospital case manager work together with providers to establish the plan of care as well as the discharge plan, taking into consideration the patient’s benefit plans and community resources.
"To work effectively and efficiently, hospital and managed care case managers must both be on the same page, understand the value each brings to coordination of patient care, and keep the patient as the center of focus," Strassner concludes. "It is imperative that the managed care case manager and the hospital-based case manager have a strong collaborative working relationship."
(For more information on cooperating with managed care case managers, see Hospital Case Management, February 1999, p. 21.)
Recommended Reading
Bodenheimer T, Casalino L. Executives with white coats: The work and world view of managed care medical directors. N Engl J Med 1999; 341:1,945-1,948, 2,029-2,032.
For more information, contact:
Paul Reich, MD, chief medical officer and consultant, The Scheur Management Group, Newton, MA. Telephone: (617) 969-7500. E-mail: SMGNOW@ SCHEUR.com.
Toni Cesta, PhD, RN, director of case management, Saint Vincents Hospital and Medical Center, New York City. Telephone: (212) 604-7992. E-mail: tcesta@ saintvincentsNYC.org.
Lawrence F. Strassner, MS, RN, Ernst and Young, LLP, Philadelphia. Telephone: (215) 448-5625. E-mail: [email protected].
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