Using integrated care management

In the era of managed care, health insurance companies historically used utilization management, care management and disease management programs to improve clinical outcomes and manage the cost of health care.

Over the last few years, those strategies have evolved into a bigger-picture approach to health care, known as integrated care management, or ICM. “ICM takes a more holistic approach to clinical care in collaboration with the health care provider to meet all of the patient’s clinical, psychosocial and environmental needs,” says Dr. Michael J. Culyba, vice president, medical affairs, at UPMC Health Plan in Pittsburgh.

Smart Business spoke with Culyba about integrated care management, and what its use means for businesses, individuals and health care providers.

What is integrated care management and how does it work?
The concept of integrated care management takes health care to the next level by recognizing that individuals with chronic diseases really have multiple conditions. Rarely, for example, do individuals have only diabetes, or only heart failure. Instead, they usually have two or more medical conditions.

If you look only at the clinical needs, and not at the whole environment of the patient, then you miss opportunities to improve the processes of care. ICM looks at the population holistically, manages each patient from a broader perspective and addresses their clinical care using evidence-based medicine and best practices. It also factors in their psychosocial and environmental needs, and ensures that those are also met.

How does ICM help medical professionals provide a better standard of care?
For starters, it addresses the idea that the health plan works collaboratively with medical professionals to identify gaps in care and to address them whenever possible. Health plans have a wealth of data and information that they can provide to physicians to improve their capability to clinically care for their patients.

Integrated care teams, for example can use predictive medicine tools to identify patients who may be at risk … (and) share this information with their physicians to better coordinate care. ICM focuses on improving the clinical process of care, which improves outcomes and positively affects resource utilization and tempers the cost of care.

How can ICM help people better manage their health?
Through ICM, the health plan can use clinical assessments to identify member needs and make suggestions to help them better manage their own care. Some may need community services, for example, while others may need transportation to and from the doctor’s office.

Still others may lack knowledge of their disease, and may need help understanding how to monitor their medical condition. Through ICM education and resources, those individuals can gain valuable insights into their own conditions working with nurses, social workers, pharmacists and other team members to ensure that their health is taken care of in a comprehensive, effective manner.

What can business owners/leaders do to encourage their employees to take advantage of ICM?
As the business world moves toward the concept of consumerism (in which consumers play a more active role in their own health care), many employers will be creating benefit designs that actually encourage the use of ICM as a modality for their employees who have medical conditions. Some employers, for example, report that once their employees complete health risk assessments, the company will remove a deductible or waive a month’s worth of their contributions. To promote the programs, employers can also market the programs in a positive fashion, and encourage employees to participate.

How does ICM improve cost effectiveness in medical settings?
If improving the quality of care and improving clinical outcomes ultimately reduces cost, then tools like ICM can ultimately have the maximum impact on cost effectiveness. It can be particularly effective when it comes to medication, since some people either forget to take them or stop taking them completely. Doing so can cause even more medical problems, which in turn lead to hospitalization or trips to the emergency room.

ICM can be effective in making sure people take their medication, leading to improved clinical care and clinical management in the outpatient environment, while reducing hospitalizations, readmissions to the hospital and emergency room visits.

How can ICM help businesses control/reduce their health care costs?
If you’re a fully-insured employer, this program will ultimately affect the overall medical trend and will allow insurance trends to temper. If you are a self-funded employer, ICM can play an integral role in helping to manage medical costs.

Dr. Michael J. Culyba is vice president, medical affairs, at UPMC Health Plan in Pittsburgh. Culyba can be reached at (412) 454-7905 or [email protected].