As your risk increases, case manager role grows
They can save money and improve patient care
Your practice is at risk for a patient with congestive heart failure who makes repeated visits for care. How do you control the time you spend on the patient and the cost to your practice?
An elderly patient needs personal care to live independently, but her insurance doesn’t cover it. How do you help her tap into community resources?
You see a number of obese, sedentary patients who could benefit from wellness activities, but your patient load doesn’t give you time to counsel them. How do you help them stay healthy?
These are all scenarios in which a case manager could help you manage the details of patient care. If your practice is bearing substantial risk for the cost of patient care, you might consider hiring a case manager to collaborate with your physicians.
"When there is an incentive to keep patients out of the office or emergency room and manage their care by phone or by self-care, case managers become quite attractive," says Kathleen Quinn, RN, MBA, director of practice management services for the University of Virginia Health Service Foundation in Charlottesville.
In the traditional fee-for-service environment, physicians may not have many incentives for hiring a case manager. But in a highly capitated environment, the incentives for hiring a case manager to work in your practice can be substantial.
The more risk, the more reward
"The more risk the physician bears for the patients’ cost of care, the more likely it is that the physician will look toward utilizing a case manager to help manage the care," says Maureen Cadogan, CCM, CPHQ, RN, principal of Cadogan Consulting in West Covina, CA. Cadogan helps medical groups put together case management programs.
The first case managers usually dealt with only high-cost catastrophic cases, such as brain injury or spinal cord injury patients, says Sue Binder, RN, CCM, principal of Integrated Healthcare Consultants in Caldwell, NJ. Her firm contracts with physician practices to manage patient care.
Now they can help take care of many of the details involved in today’s patient care, leaving physicians free to assess, diagnose, and treat patients, she adds.
"The whole practice of medicine has changed radically from being paid for treating the sick to a capitated system which rewards the physician to keep the patient well," Binder says.
Because of their experiences with insurance company case managers, some physicians may feel that case managers are trying to second-guess the doctors, says Binder. But that’s not true, she says, adding that case managers are collaborators with the doctors.
"The physician has to focus on the clinical aspects, but there are many other areas of patient care where the case manger can collaborate," Binder says. (For information on the jobs case managers can take on, see article on p. 61.)
Case management still is fairly rare in physician practices, but some groups are finding it beneficial.
Pediatric home visits
Most of the University of Virginia clinics are still paid on a fee-for-service basis. However, the pediatric office has some risk-bearing contracts and uses case managers for everything from visiting newborns at home to managing chronic or terminal diseases.
Now that new mothers are being discharged from the hospital so quickly, the UVA clinics find that routine well-care visits by case managers can make a difference. The case manager can check on the baby, answer the mother’s questions, help new mothers avoid an unnecessary office visit, or make sure they bring the baby in if there is a need for it.
"So many first-time mothers are unsure of themselves and they don’t live close to their mothers and grandmothers. If their baby needs to be seen, judgment calls are hard to make," Quinn says.
The case managers also help families manage the care of children with chronic or terminal diseases such as asthma, leukemia, or cystic fibrosis. Their interventions help reduce emergency room visits and admission to the hospitals, Quinn says.
"Our payer mix is still heavily weighted toward fee for service. As the payer market changes, we will be more incentivized to use case managers," Quinn says.
Instead of having its own case manager, Greensboro (NC) Orthopedic Center employs a nurse who acts as a liaison to case managers, particularly in workers’ compensation cases, says John Nosek, MPA, CMPE, executive director.
"Her role is to make sure the patient care is completed as effectively and as efficiently as possible and to make sure our workers’ comp patients don’t fall into a black hole," Nosek says.
For instance, Nosek’s case manager makes sure patients are getting to therapy, helps get the patients back to work, and notifies the insurance company if patients aren’t compliant.
"It has an indirect monetary benefit, because if patients are out of work a shorter length of time than is the norm, we are apt to get more employers to send patients to us," Nosek says.
One of the practice’s workers’ compensation employers has the lowest out-of-work rate in the nation for his company, Nosek says.
[Editor’s note: For more information on standards of practice and credentialing of case managers, contact the Case Management Society of America, 8201 Cantrell Road, Suite 230, Little Rock, AR 72227. Telephone: (501) 225-2229. E-mail: [email protected]. Web site: www.cmsa.org.]
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