Integrating utilization and case management for optimal results

Medical management programs are typically comprised of multiple services designed to help control health care costs and ensure optimal health outcomes for employees.

“While these sorts of programs can be used individually, they are really intended to work together to provide an integrated approach to managing an employee’s total health,” says Amy Cleveland, HealthLink director of Medical Management.

Employers who don’t have a complete understanding of medical management programs may be missing out on the many advantages of an integrated approach by “carving out” or removing certain programs and services.

“When employers leave even one medical management service out of their plan, the program does not work as intended, which can put the good health of their employees and their spending at risk,” Cleveland says.

Smart Business spoke with Cleveland about integrating medical management.

What is utilization management?

Utilization management (UM) consists of multiple programs designed to encourage appropriate use and performance of medical services in accordance with evidence-based guidelines. Typically, UM consists of pre-certification reviews for hospital admissions, certain medications and high-tech imaging services, such as MRIs and CAT scans, as well as continued stay review, discharge planning, proactive screening for case management (CM) and more. These services can ensure employees get the right level of care at the right time, and that their treatment meets the health plan’s standards.

How should CM work?

CM nurses are responsible for developing individualized care plans for employees identified as at-risk for high utilization and/or high dollar claims. These plans assist employees with complex care needs, improve their experience, promote safe and timely transitions in care and encourage efficient delivery of services and cost savings. The CM team’s goal is to assist in an employee’s recovery to help them navigate the health care system and offer added support.

What are the advantages of integrating these programs?

When UM and CM are fully integrated, it allows for a comprehensive approach to managing employees’ health. Employees can be proactively screened during the UM process and clinical reviews to see if they are a candidate for CM. These high-risk employees can then be engaged much sooner, which leads to better health outcomes. This sort of integration gives CM teams the ability to engage employees in real time, rather than using past claims data to determine eligibility. It also allows for regular communication and coordination between the UM and CM nurses to ensure care plans are as customized and patient-focused as possible. This elevates a medical management program to real-time engagement in the quality of care.

What are the downfalls of carving one of these services out?

When one program is carved out, the other cannot work as effectively. If an employer chooses CM services, but not UM, employees can no longer be pre-screened and engaged in real time. In this instance, utilization and spending reports would be the only tool used to attempt to identify high-risk employees. Often, these employees don’t need services anymore. The opportunity to help employees and contain costs is missed.

How can employers decide if integrated medical management is right for them?

For many employers, cost containment is a driving factor for considering a medical management program. Unfortunately, most employers don’t fully understand the major advantages to employee health and cost containment opportunities that a complete, fully-integrated program offers.

Employers who are considering a medical management program should talk to their broker, third party administrator, network partner or carrier to be fully educated about the impact a medical management program can have on their health plan.

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