- Email: [email protected]
Case management in managed care
v
9
v
years and, from all appearances, shows no signs of slowing down. This article attempts to lay out the factors that will lead to the future of CM from three perspectives: patients, providers, and payers
the
trilogy of the health care industry. The content of
-
j,
the bulk of CM activity centers on this group. Focusing on the population segment that spends a large percentage of the health care dollars available still makes sense today. However, a move is afoot to scale up services to either "at risk" or entire populations. This trend definitely has been irifluenced by accrediting bodies, such as the National Committee for Quality Assurance (NCQA), that requ, ire a broader focus across a health plan's membership and is aided b y new technologies that facilitate tracking large groups of people.
this article is rather provocative, intentionally designed to kindle thought and generate alternative ways to approach CM programs.
Expanding to do this w o r k is not in the reahn of possibility for traditional CM services that are designed to manage only exceptional cases in low volumes. Not long ago, case managers had accorSeptember/October 1999
TCM
37
dion files of 30 to 50 cases that could be transported to their cars for visits to homes, provider offices, etc. Case m a n agers relied on m a n u a l systems to track their cases, using h o m e g r o w n alert a n d r e m i n d e r systems to tell t h e m w h a t to do next. Yellow sticky notes were everywhere. It also wasn't long ago that m a n y case managers were i n d e p e n d e n t entities w h o functioned on a freelance basis. Although these entrepreneurial case managers still exist, their numbers are d w i n d l i n g relative to the total case manager population. Managed care companies have recognized the value of coordinating services a n d providers a n d have swallowed u p these case managers at an astounding rate. Physicians, once the ultimate case manager w h e n times a n d p a y m e n t options were simpler, are no longer the absolute masters of their domains. Although physicians remain central to point of service care, they have lost their dominant role in matters of health care utilization. The early battles between case managers and physicians were lege n d a r y and resulted in unfortunate schisms between the point of service and the point of payment. M a n a g e d care in any form started with an eye toward cost-containment b y using the p o w e r of volume discounts and risk arrangements. Third party reimbursement strategies p u s h e d health care into a c o m m o d i t y mentality rather than a service industry. Utilization management and review processes, a "twisted root" origin of CM, served the n e e d to rein in costs while placating physicians a n d patients alike. The notion of monitoring transactions led to the proliferation of a u t o m a t e d systems that s p a w n e d whole industries to feed this need. Physicians learned to code their w o r k (and game the system) for payment, technology companies scrambled to build complex claims databases, m e d ical taxonomy companies d e v e l o p e d and maintained coding categories, a n d businesspeople j u m p e d into the fray to "manage" the m o n e y - - b u t not the health care.
TCM 38
S~p,,mb~/O~ob~,~999
State of the Union for Health Care Systems Describing the current situation for case managers is always problematic. The perspective is more accurate w h e n we look back and is almost mystical w h e n we presume the future. Perhaps it will be helpful to evaluate the current health care system performance first from a conceptual level. To illustrate this perspective, let's look at h o w our three groups interact with health care using inefficient models.'
The patient's perspective. Linear, circular, or matrix models that assume a patient moves from one level of care to another are absolutely wrong. Anyone w h o has provided direct care knows patients rarely move neatly between settings. These models are very c o m m o n a n d are the basis for m a n y of the niche or boutique health care venues that start with "step down," "skilled," or "subacute." Implied in this w a y of thinking is that somehow the intensity of care received can be gauged a n d that intensity should decrease over time and in a linear fashion. Of course, times and places exist w h e n care is intensified, but this situation is not as predictable as the beancounters think. For instance, some patients w h o require an intensive care stay are not necessarily receiving "higher levels" of care than those w h o require home health. This notion is more a marketing and pricing ploy than one of true medical resource drain. Instead, patients require w h a t they require on their o w n terms and in their o w n time. Manufacturers call this a "just in time" system. If they h a d to move their products through the kind of processes required in health care, n o n e of us w o u l d be able to afford them. Patients should be able to access a toolbox of interventions that stand on their o w n without absolute d e p e n d e n c e on each other to occur. The idea that a patient has to "qualify" through preauthorization for a given benefit is flawed because not e v e r y b o d y has the same natural history t h r o u g h a disease process. Take heart disease as an example. For fully 40% of people with this disease, the first sign or s y m p t o m is s u d d e n death. Where's the process
here? Sad to say, m a n y of these now d e a d patients probably d i d n ' t qualify for a cardiac treadmill test or other health promotion (and life-saving) interventions because of a lack of preexisting conditions! Finally, patients in general are not prov i d e d a w a y to measure or track their o w n health care. Despite the current sophistication of patient education materials in all forms, professional support to make sure patients u n d e r s t a n d w h a t they should do to take care of themselves is still u n d e r w h e l m i n g . Patients n e e d an "owner's manual" for their body. M a n y patients readily can find out w h e n to change the fan belt in their car b u t w o u l d be hard-pressed to find the correct i m m u n i z a t i o n schedule for themselves.
The provider' s perspective. N o w h e r e in any industry is so much ultimate responsibility placed on one person (the physician) and so little s u p p o r t provided. As a result, a typical physician's d a y consists of 7- to 15-minute clinic appointments with patients w h o are illequipped to manage their o w n condition. Physicians do not intentionally withhold or sabotage care, yet research points to suboptimal care for patients with chronic illness? Very p o o r medical record reliability that does not support such basic needs as trending data and prompts for health prevention tests (schedule for preventive examinations) contributes to this unfortunate aspect of health care. Low or no reimbursement for interventions that will dramatically affect patient health status a n d reduce unnecessary medical costs also m a y contribute to the lack of screening tests. Recent market analysis using patient a n d physician focus groups have yielded interesting results in this regardr 9 Patients d o n ' t necessarily believe their physician has all the tools to manage their condition. 9 Patients feel shortchanged b y the lack of time with physicians a n d question their listening abilities. 9 General practice physicians are at odds with health plans in general, and
a healthy amount of distrust exists with health plan motivation to curtail medical loss ratios. 9 Specialty physicians, on the other hand, are more confident with outside assistance (case/disease management programs). They appreciate the help and in general d o n ' t feel threatened.
The payer's perspective. Most managed care companies are moving from transactions to medical care oversight. We have suffered severely from simpleminded, transaction-based thinking. Health plan leaders appear to be making sincere efforts to partner with their providers to provide medical management oversight that will lead to better health services and outcomes. The advent of accreditation companies like NCQA are holding the payers' feet to the fire by requiring a more comprehensive approach to medical management. The proliferation of disease management services is testimony to the affect of NCQA on health plans. Benefit structures, although improving, and problems with logical consistency are tied more to premium dollars than clinical appropriateness. Denying a glucose meter for a noninsulin-requiring diabetic who has just had a heart attack is one example of m a n y possibilities. Finally, proving the value of CM always has been a challenge; unfortunately, it's not getting any easier. Legacy systems designed to track transactions often are cumbersome and inadequate when queried for CM analysis reasons. When discussions turn to return on investment, the "you prove it/no, YOU prove it" mentality remains. Recent claims analysis studies looking at the real story behind the accuracy of data are not promising, 4 although at least one health plan seems to have a handle on its datar
The Future ix Now In Case Management for Health Professionals,6 four dimensions of CM were proposed as a means to explore the interrelationships of various systems. From the perspective of our three-way orientation, three of these dimensions will serve as a framework for how CM will evolve in the coming years.
Self-Care CM--Patient The patients are the central actors in this form of CM and are responsible for coordinating appropriate services (for themselves) to the best of their ability. Patients have varying degrees of abilities to perform this function and frequently have significant knowledge and competency deficits in this area. Many examples are available of how patients can increase their self-care abilities; here are a few that will dominate the landscape and, if included in a comprehensive CM program, will contribute to meaningful outcomes: On-demand expert medical advice. When asked, patients will say they prefer to access nonacute health information on a "need to know" basis. 7 Many patients will use home health books, Internet sources, audio health libraries, and knowledgeable friends long before seeking help from their physicians.
aspect of their practice. Disease management programs fill this gap with specially trained RNs and other related professionals. Intervention. Very often, patients require something to "happen" as a result of their situation. Sometimes these services are handled easily by the patient, such as a referral to a local class. Times arise, however, when the patient requires a more complicate~l intervention, such as qualifying for a home nebulizer or an appointment with a subspecialist. Newly formed open-access systems of care will help patients navigate the system, but they still would benefit from a guide. This function is not unlike the traditional role of case managers w h o are responsible for service coordination and again are available through a nurse-mediated disease management program.
Primary CM--Physician Triage services. Patients appreciate decision support when they think they have or might have overwhelmed their ability to care for themselves. Triage--routing a patient with a medical need to the most appropriate setting--is a tried and true method of ensuring appropriate medical utilization. For instance, close to 40% of all callers to one large triage system result in self-care advice, not an appointment with a physidan. 8
Primary care CM occurs between the physician and the patient. In this setring, effective CM can occur only with robust data collection systems that incorporate guideline-based prompting systems. These systems should be designed to move the patient along in a way that reduces the likelihood of missing or withholding key management practices. Several exciting new possibilities for enhancing primary care CM are available:
Health promotion, disease prevention, and disease management. As stated earlier, patiehts deserve an owner's manual for the body, a guidebook that can be real or conceptual but includes at a minimum mechanisms for prompting screening tests, trending results, basic education, and decision support for self-care activities (the reasons screening tests are important, for instance). Applications for these services exist and are in use today.
Practice augmentation. The physician's efficiency will increase exponentially with effective disease management tools designed to provide monitoring, education, and logistical support of patients between office visits.
Education. Education presented in a timely manner that is perceived by the patient as necessary and by the provider as sound is a very effective method of minimizing untoward events. Many physicians realize they do not spend enough rime on this
9 Monitoring services. Such services act as a physician surrogate, trolling patients for newly developed or wors.ening problems. Early identification of these problems and subsequent routing back to the physician in a timely fashion dramatically decrease the need for inappropriate ED visits or hospitalization. Remote monitoring services. These are emerging as a valuable tool for the physician; examples include remote September~October1999
TCM 39
weight scales, 9 two-way monitoring devices with algorithm logic, 1~and even automated pill dispensers with "smart" logic that extends past a pill timer, n All these services are designed to poll their users and report back findings to individual physicians and case managers. Early reports from both physicians and patients are positive.
Health risk screening focuses on primary and secondary risk elements with an eye toward developing a plan to reduce those risks. Health risk screening is not now nor has ever been an effective intervention that reduces medical loss ratios. Instead, this type of screening may be more useful as a way of identifying and routing members into no-risk,. at-risk, or high-risk intervention pools.
9 Prompts. Physicians rely on prompts all the time to help them remember to perform routine tasks, such as annual flu shots. New systems that track routine patient needs will promote better adherence to guidelines, enhance patient health status, and increase early identification of impending problems. A system of prompts can take the form of written check sheets in the medical record, automatically generated prompt sheets from an electronic medical record, or the patient's own maintenance record.
Illness risk appraisal focuses on finding members with established conditions (eg, asthma, diabetes, heart failure, pregnancy) or those with a high likelihood of a condition (eg, significant family history of heart disease and elevated cholesterol). This appraisal has the look and feel of an insurance physical and does not compute risk like a health appraisal. Health plans find this information more immediately useful than a health risk appraisal because of its ability to efficiently identify potential cost drivers before a claim is generated.
Brokered CM--Payer
Conclusion
From the payer perspective, future systems of care will need to more closely integrate data from both patient and physician activity. Future CM will marry the various "data truths" of medical, pharmacy, laboratory, and physicianand patient-reported data into one source to develop a clearer understanding of the situation. Several companies are attempting to clean up and make sense of these disparate data sources on behalf of the payers, but to date these products qualify as only data inspection tools, not necessarily health care enhancing tools.
Even though case managers in managed care are undergoing radical change, the elements of change are familiar and tantalizing. This article is conceptual, forward-thinking, and thus may be frustrating to those who desire a step-bystep approach to the future of CM.
Plans also will become much more involved with member screening for medical management and routing purposes. Until now, payers have waited far downstream for claims to occur, m a n y of which are preventable. N o w payers are much more interested in knowing w h o m they are taking care of before they do so! At least two methods come to mind regarding member screening: health and illness risk screening.
TCM 40
September/October1999
Understanding the trilogy of patient, provider, and payer in a CM context is not new, but incorporating the notion of how certain dimensions might emerge may be. How many of us consider the "self-care" aspect of CM as strongly as suggested in this article? Hopefully, a few things mentioned herein have sparked an idea that will help you put our industry into perspective and enable you to anticipate and set the standard for future improvements in your own setting. Q
2. Davis DA, et al. Changing physician performance. JAMA 1995;274:700-4. 3. Unpublished material from three focus group sessions in Baltimore, Chicago, and Houston. Participants were family practice, internal medicine, and specialist physicians and separate groups of high risk patients with diabetes and congestive heart failure. 4. Fowles JB. Comparing claims data and self-reported data with the medical record for Pap smear rates. Eval Health Prof 1997;20:324-42. 5. Wagner EH. The promise and performance of HMOs in improving outcomes in older adults. J Am Geriatr Soc 1996;44:1251-7. 6. Howe R. Case management for health care professionals. Chicago: Precept Press; 1992. 7. Unpublished research conducted for medical access purposes in one large military catchment area. More than 60% of people ranked on-demand expert advice as the number-one feature of their health care system. 8. Triage results study. 9. Alere Medical Inc., 120 Montgomery St., Ste. 750, San Francisco, CA 941044303; (415) 439-6700. 10. Health Hero Network Inc., 2570 W E1 Camino Real, Ste. 520, Mountain View, CA 94040 (650) 949-3933. 11. Intormedix, Inc., 5920 Hubbard Dr., Rockville, MD 20852; (301) 984-1566.
Rufus S. Howe, FNP, is the vice president of product integration for McKessonHBOC, Access Health Group in, Broomfield, Col.
References 1. Vladek B. The continuum of care: principles and metaphors. In: Managing the continuum of care. Gaithersburg (MD): Aspen Publications; 1987. p. 3-9.
Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/220
9
v
years and, from all appearances, shows no signs of slowing down. This article attempts to lay out the factors that will lead to the future of CM from three perspectives: patients, providers, and payers
the
trilogy of the health care industry. The content of
-
j,
the bulk of CM activity centers on this group. Focusing on the population segment that spends a large percentage of the health care dollars available still makes sense today. However, a move is afoot to scale up services to either "at risk" or entire populations. This trend definitely has been irifluenced by accrediting bodies, such as the National Committee for Quality Assurance (NCQA), that requ, ire a broader focus across a health plan's membership and is aided b y new technologies that facilitate tracking large groups of people.
this article is rather provocative, intentionally designed to kindle thought and generate alternative ways to approach CM programs.
Expanding to do this w o r k is not in the reahn of possibility for traditional CM services that are designed to manage only exceptional cases in low volumes. Not long ago, case managers had accorSeptember/October 1999
TCM
37
dion files of 30 to 50 cases that could be transported to their cars for visits to homes, provider offices, etc. Case m a n agers relied on m a n u a l systems to track their cases, using h o m e g r o w n alert a n d r e m i n d e r systems to tell t h e m w h a t to do next. Yellow sticky notes were everywhere. It also wasn't long ago that m a n y case managers were i n d e p e n d e n t entities w h o functioned on a freelance basis. Although these entrepreneurial case managers still exist, their numbers are d w i n d l i n g relative to the total case manager population. Managed care companies have recognized the value of coordinating services a n d providers a n d have swallowed u p these case managers at an astounding rate. Physicians, once the ultimate case manager w h e n times a n d p a y m e n t options were simpler, are no longer the absolute masters of their domains. Although physicians remain central to point of service care, they have lost their dominant role in matters of health care utilization. The early battles between case managers and physicians were lege n d a r y and resulted in unfortunate schisms between the point of service and the point of payment. M a n a g e d care in any form started with an eye toward cost-containment b y using the p o w e r of volume discounts and risk arrangements. Third party reimbursement strategies p u s h e d health care into a c o m m o d i t y mentality rather than a service industry. Utilization management and review processes, a "twisted root" origin of CM, served the n e e d to rein in costs while placating physicians a n d patients alike. The notion of monitoring transactions led to the proliferation of a u t o m a t e d systems that s p a w n e d whole industries to feed this need. Physicians learned to code their w o r k (and game the system) for payment, technology companies scrambled to build complex claims databases, m e d ical taxonomy companies d e v e l o p e d and maintained coding categories, a n d businesspeople j u m p e d into the fray to "manage" the m o n e y - - b u t not the health care.
TCM 38
S~p,,mb~/O~ob~,~999
State of the Union for Health Care Systems Describing the current situation for case managers is always problematic. The perspective is more accurate w h e n we look back and is almost mystical w h e n we presume the future. Perhaps it will be helpful to evaluate the current health care system performance first from a conceptual level. To illustrate this perspective, let's look at h o w our three groups interact with health care using inefficient models.'
The patient's perspective. Linear, circular, or matrix models that assume a patient moves from one level of care to another are absolutely wrong. Anyone w h o has provided direct care knows patients rarely move neatly between settings. These models are very c o m m o n a n d are the basis for m a n y of the niche or boutique health care venues that start with "step down," "skilled," or "subacute." Implied in this w a y of thinking is that somehow the intensity of care received can be gauged a n d that intensity should decrease over time and in a linear fashion. Of course, times and places exist w h e n care is intensified, but this situation is not as predictable as the beancounters think. For instance, some patients w h o require an intensive care stay are not necessarily receiving "higher levels" of care than those w h o require home health. This notion is more a marketing and pricing ploy than one of true medical resource drain. Instead, patients require w h a t they require on their o w n terms and in their o w n time. Manufacturers call this a "just in time" system. If they h a d to move their products through the kind of processes required in health care, n o n e of us w o u l d be able to afford them. Patients should be able to access a toolbox of interventions that stand on their o w n without absolute d e p e n d e n c e on each other to occur. The idea that a patient has to "qualify" through preauthorization for a given benefit is flawed because not e v e r y b o d y has the same natural history t h r o u g h a disease process. Take heart disease as an example. For fully 40% of people with this disease, the first sign or s y m p t o m is s u d d e n death. Where's the process
here? Sad to say, m a n y of these now d e a d patients probably d i d n ' t qualify for a cardiac treadmill test or other health promotion (and life-saving) interventions because of a lack of preexisting conditions! Finally, patients in general are not prov i d e d a w a y to measure or track their o w n health care. Despite the current sophistication of patient education materials in all forms, professional support to make sure patients u n d e r s t a n d w h a t they should do to take care of themselves is still u n d e r w h e l m i n g . Patients n e e d an "owner's manual" for their body. M a n y patients readily can find out w h e n to change the fan belt in their car b u t w o u l d be hard-pressed to find the correct i m m u n i z a t i o n schedule for themselves.
The provider' s perspective. N o w h e r e in any industry is so much ultimate responsibility placed on one person (the physician) and so little s u p p o r t provided. As a result, a typical physician's d a y consists of 7- to 15-minute clinic appointments with patients w h o are illequipped to manage their o w n condition. Physicians do not intentionally withhold or sabotage care, yet research points to suboptimal care for patients with chronic illness? Very p o o r medical record reliability that does not support such basic needs as trending data and prompts for health prevention tests (schedule for preventive examinations) contributes to this unfortunate aspect of health care. Low or no reimbursement for interventions that will dramatically affect patient health status a n d reduce unnecessary medical costs also m a y contribute to the lack of screening tests. Recent market analysis using patient a n d physician focus groups have yielded interesting results in this regardr 9 Patients d o n ' t necessarily believe their physician has all the tools to manage their condition. 9 Patients feel shortchanged b y the lack of time with physicians a n d question their listening abilities. 9 General practice physicians are at odds with health plans in general, and
a healthy amount of distrust exists with health plan motivation to curtail medical loss ratios. 9 Specialty physicians, on the other hand, are more confident with outside assistance (case/disease management programs). They appreciate the help and in general d o n ' t feel threatened.
The payer's perspective. Most managed care companies are moving from transactions to medical care oversight. We have suffered severely from simpleminded, transaction-based thinking. Health plan leaders appear to be making sincere efforts to partner with their providers to provide medical management oversight that will lead to better health services and outcomes. The advent of accreditation companies like NCQA are holding the payers' feet to the fire by requiring a more comprehensive approach to medical management. The proliferation of disease management services is testimony to the affect of NCQA on health plans. Benefit structures, although improving, and problems with logical consistency are tied more to premium dollars than clinical appropriateness. Denying a glucose meter for a noninsulin-requiring diabetic who has just had a heart attack is one example of m a n y possibilities. Finally, proving the value of CM always has been a challenge; unfortunately, it's not getting any easier. Legacy systems designed to track transactions often are cumbersome and inadequate when queried for CM analysis reasons. When discussions turn to return on investment, the "you prove it/no, YOU prove it" mentality remains. Recent claims analysis studies looking at the real story behind the accuracy of data are not promising, 4 although at least one health plan seems to have a handle on its datar
The Future ix Now In Case Management for Health Professionals,6 four dimensions of CM were proposed as a means to explore the interrelationships of various systems. From the perspective of our three-way orientation, three of these dimensions will serve as a framework for how CM will evolve in the coming years.
Self-Care CM--Patient The patients are the central actors in this form of CM and are responsible for coordinating appropriate services (for themselves) to the best of their ability. Patients have varying degrees of abilities to perform this function and frequently have significant knowledge and competency deficits in this area. Many examples are available of how patients can increase their self-care abilities; here are a few that will dominate the landscape and, if included in a comprehensive CM program, will contribute to meaningful outcomes: On-demand expert medical advice. When asked, patients will say they prefer to access nonacute health information on a "need to know" basis. 7 Many patients will use home health books, Internet sources, audio health libraries, and knowledgeable friends long before seeking help from their physicians.
aspect of their practice. Disease management programs fill this gap with specially trained RNs and other related professionals. Intervention. Very often, patients require something to "happen" as a result of their situation. Sometimes these services are handled easily by the patient, such as a referral to a local class. Times arise, however, when the patient requires a more complicate~l intervention, such as qualifying for a home nebulizer or an appointment with a subspecialist. Newly formed open-access systems of care will help patients navigate the system, but they still would benefit from a guide. This function is not unlike the traditional role of case managers w h o are responsible for service coordination and again are available through a nurse-mediated disease management program.
Primary CM--Physician Triage services. Patients appreciate decision support when they think they have or might have overwhelmed their ability to care for themselves. Triage--routing a patient with a medical need to the most appropriate setting--is a tried and true method of ensuring appropriate medical utilization. For instance, close to 40% of all callers to one large triage system result in self-care advice, not an appointment with a physidan. 8
Primary care CM occurs between the physician and the patient. In this setring, effective CM can occur only with robust data collection systems that incorporate guideline-based prompting systems. These systems should be designed to move the patient along in a way that reduces the likelihood of missing or withholding key management practices. Several exciting new possibilities for enhancing primary care CM are available:
Health promotion, disease prevention, and disease management. As stated earlier, patiehts deserve an owner's manual for the body, a guidebook that can be real or conceptual but includes at a minimum mechanisms for prompting screening tests, trending results, basic education, and decision support for self-care activities (the reasons screening tests are important, for instance). Applications for these services exist and are in use today.
Practice augmentation. The physician's efficiency will increase exponentially with effective disease management tools designed to provide monitoring, education, and logistical support of patients between office visits.
Education. Education presented in a timely manner that is perceived by the patient as necessary and by the provider as sound is a very effective method of minimizing untoward events. Many physicians realize they do not spend enough rime on this
9 Monitoring services. Such services act as a physician surrogate, trolling patients for newly developed or wors.ening problems. Early identification of these problems and subsequent routing back to the physician in a timely fashion dramatically decrease the need for inappropriate ED visits or hospitalization. Remote monitoring services. These are emerging as a valuable tool for the physician; examples include remote September~October1999
TCM 39
weight scales, 9 two-way monitoring devices with algorithm logic, 1~and even automated pill dispensers with "smart" logic that extends past a pill timer, n All these services are designed to poll their users and report back findings to individual physicians and case managers. Early reports from both physicians and patients are positive.
Health risk screening focuses on primary and secondary risk elements with an eye toward developing a plan to reduce those risks. Health risk screening is not now nor has ever been an effective intervention that reduces medical loss ratios. Instead, this type of screening may be more useful as a way of identifying and routing members into no-risk,. at-risk, or high-risk intervention pools.
9 Prompts. Physicians rely on prompts all the time to help them remember to perform routine tasks, such as annual flu shots. New systems that track routine patient needs will promote better adherence to guidelines, enhance patient health status, and increase early identification of impending problems. A system of prompts can take the form of written check sheets in the medical record, automatically generated prompt sheets from an electronic medical record, or the patient's own maintenance record.
Illness risk appraisal focuses on finding members with established conditions (eg, asthma, diabetes, heart failure, pregnancy) or those with a high likelihood of a condition (eg, significant family history of heart disease and elevated cholesterol). This appraisal has the look and feel of an insurance physical and does not compute risk like a health appraisal. Health plans find this information more immediately useful than a health risk appraisal because of its ability to efficiently identify potential cost drivers before a claim is generated.
Brokered CM--Payer
Conclusion
From the payer perspective, future systems of care will need to more closely integrate data from both patient and physician activity. Future CM will marry the various "data truths" of medical, pharmacy, laboratory, and physicianand patient-reported data into one source to develop a clearer understanding of the situation. Several companies are attempting to clean up and make sense of these disparate data sources on behalf of the payers, but to date these products qualify as only data inspection tools, not necessarily health care enhancing tools.
Even though case managers in managed care are undergoing radical change, the elements of change are familiar and tantalizing. This article is conceptual, forward-thinking, and thus may be frustrating to those who desire a step-bystep approach to the future of CM.
Plans also will become much more involved with member screening for medical management and routing purposes. Until now, payers have waited far downstream for claims to occur, m a n y of which are preventable. N o w payers are much more interested in knowing w h o m they are taking care of before they do so! At least two methods come to mind regarding member screening: health and illness risk screening.
TCM 40
September/October1999
Understanding the trilogy of patient, provider, and payer in a CM context is not new, but incorporating the notion of how certain dimensions might emerge may be. How many of us consider the "self-care" aspect of CM as strongly as suggested in this article? Hopefully, a few things mentioned herein have sparked an idea that will help you put our industry into perspective and enable you to anticipate and set the standard for future improvements in your own setting. Q
2. Davis DA, et al. Changing physician performance. JAMA 1995;274:700-4. 3. Unpublished material from three focus group sessions in Baltimore, Chicago, and Houston. Participants were family practice, internal medicine, and specialist physicians and separate groups of high risk patients with diabetes and congestive heart failure. 4. Fowles JB. Comparing claims data and self-reported data with the medical record for Pap smear rates. Eval Health Prof 1997;20:324-42. 5. Wagner EH. The promise and performance of HMOs in improving outcomes in older adults. J Am Geriatr Soc 1996;44:1251-7. 6. Howe R. Case management for health care professionals. Chicago: Precept Press; 1992. 7. Unpublished research conducted for medical access purposes in one large military catchment area. More than 60% of people ranked on-demand expert advice as the number-one feature of their health care system. 8. Triage results study. 9. Alere Medical Inc., 120 Montgomery St., Ste. 750, San Francisco, CA 941044303; (415) 439-6700. 10. Health Hero Network Inc., 2570 W E1 Camino Real, Ste. 520, Mountain View, CA 94040 (650) 949-3933. 11. Intormedix, Inc., 5920 Hubbard Dr., Rockville, MD 20852; (301) 984-1566.
Rufus S. Howe, FNP, is the vice president of product integration for McKessonHBOC, Access Health Group in, Broomfield, Col.
References 1. Vladek B. The continuum of care: principles and metaphors. In: Managing the continuum of care. Gaithersburg (MD): Aspen Publications; 1987. p. 3-9.
Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/220