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Disease management
The problem, however, is that DM tends to take a condition-specific approach. Organizations often have separate DM teams for each disease or medical condition. The challenge for the case manager, then, is to try to coordinate patient care among DM silos. This fragmentation is especially challenging when patients have multiple chronic conditions, each of which is monitored by a separate team. Complex issues arise regarding the priority of care. If the patient has heart failure and diabetes, for example, which treatment plan comes first? More importantly, do the separate treatment plans work in the best interest of the patient? Today, many times the answer is no.
by Mindy Owen, RN, CRRN, CCM
A
s case managers have learned, disease management is an important strategy to help meet the health care needs of patients with serious chronic conditions, such as diabetes and cardiovascular disease. Case management (CM) and disease management (DM) have proved to be powerful complementary strategies; while the case manager provides access to the right health care resources in a timely and cost-effective manner, the disease manager works with specific populations to improve patient self-care and education and to maximize the efficacy of treatment.
This fractured approach to DM is neither cost-effective nor focused on patient, provider, or employer satisfaction. “No clinician would tell you that this was the ideal way of providing quality of care for a member, nor would any member tell you that there was a level of satisfaction to having four or five people working with them,” observed Cheri Lattimer, executive vice president of clinical services for Health Integrated, an advanced CM solution company that offers integrated medical and behavioral services to clients. “As we look at our population today, our patients don’t neatly fit into one diagnosis. They are dealing with more than one condition rather than just having, for example, either asthma or congestive heart failure. We need to address the whole patient, not the diseases that the patient is dealing with.” A Holistic, Patient-Centered Approach Clearly, an integrated approach that incorporates CM and DM models is called for. The result will be a more holistic, patient-centered approach that uses managers who are experts in their fields and generalists who can deal with a variety of diseases and health-related issues. Regardless of whether a patient suffers from one chronic condition or several, the point of contact is a CM/DM team that has access to clinical experts. With this integrated approach, the patient works with one disease manager who can address several different clinical conditions. At the same time, the case manager is working to facilitate treatMay/June 2004
TCM 45
the ability of case managers and disease managers to work more collaboratively. This partnership means not only addressing the patient from a medical needs standpoint but behavioral as well. Once again, the objective is to take care of the whole person, not just one aspect or condition.
The aging population will create an increased number of older workers dealing with one or more chronic health conditions that will affect their productivity. ment in a more streamlined environment with effective communication and coordinated comprehensive care. “Take this scenario: Mrs. Jones has five chronic disease states and has been assigned to five different disease managers, all sitting in different departments/companies. And she has a case manager in a sixth company. Think of the administrative costs to have six entities to provide services to the same patient! As they look at the impact of services, return on investment, and value added to the patient, these six companies will speak to the same emergency room visits, clinical visits, hospital stays, and length of stays. And they will also be claiming to save Mrs. Jones and the health plan money,” Lattimer continued.
For more information or to obtain an application to become a certified case manager, contact the Commission for Case Manager Certification at (847) 818-0292 or www.ccmcertification.org.
TCM 46
May/June 2004
“Now consider a scenario that has integrated DM and CM and calls it ‘total patient management’ or ‘care coordination.’ There is one cost, and the integrated team is totally responsible for Mrs. Jones, no matter what the illness or disease. Now when they report back on such factors as ER visits, hospitalizations, and so forth, the results are more accurate when they show improvement in clinical health status and produce member satisfaction,” she added. The integrated approach to DM, as a complement to CM, is becoming increasingly important. The aging population will create an increased number of older workers dealing with one or more chronic health conditions that will affect their productivity. At the same time, employers and health care providers will look for ways to better allocate scarce resources, while meeting the needs of this patient population. Integrating Behavioral Health The prospect of even greater demands being put on the health care system, which is already dealing with spiraling cost inflation, adds a sense of urgency to
For example, patients with more than one chronic health condition may also be dealing with depression, which must be recognized and addressed. Case managers have a responsibility to include depression screening tools in their assessment of this population and raise the awareness of the impact depression has on the total plan of care. Addressing the needs of the whole patient improves the efficacy of treatment, and by treating the depression, patients have a higher likelihood of enrolling and being active participants in DM programs. “The medical and behavioral disease components must be integrated as a whole deliverable if you want to take care of the whole person,” Lattimer added. Lessons of High-Risk Pools The benefits of integrated CM and DM strategies are being reaped within a specific patient population that consumes a disproportionate amount of health care resources— patients in state-sponsored high-risks pools. With pre-existing conditions that make them ineligible for other insurance programs, these individuals enroll in the high-risk pools that now are offered in more than 30 states. Total enrollment in the high-risk pools is about 172,000 people, with claims totaling $1 billion, or roughly $5800 per person. Enrollees in these pools pay high premiums—equivalent to 105% to 200% of the average market premium—and deductibles ranging from $5000 to $10,000. In virtually all states with high-risk pools, insurance companies must pay assessments to make up the deficit between premiums received and claims paid. Thus, many parties—insurance companies, health care providers, patients, state legislatures—have vested interests to control costs while providing
When CM is coupled with an integrated DM approach, the result can be better, more responsive, and cost-effective care. quality care to this population, which is often described as “the sickest of the sick.” By using CM and DM strategies, however, high-risk pools are able to make strides in quality and cost-effective care, including eliminating unnecessary duplication of services, improving patient self-care to promote wellness, and reducing costly ER visits and lengthy hospital stays. Importantly, this approach is not about denial of services but rather allocating the right resources to treat the whole patient in a timely and cost-effective fashion. This goal is the essence of CM and fits well within a DM model that works to bring the patient to the highest level of wellness possible, even when an individual is dealing with several comorbidities. Already these integrated CM/DM approaches are reaping cost savings within the high-risk pools. This experience can serve as an important lesson in other patient populations—including the growing number of older workers— that face more than one chronic health issue. Importance of Outcomes As CM and DM strategies are implemented, results must be tracked to measure the clinical and financial benefits. This means data must be collected and analyzed to determine and quantify improvements in patient health and the cost benefit. One of the challenges in measuring outcomes, however, has been to meet the demands of the clinical side and the financial side. For example, in a managed care environment, the financial side looks for evidence of cost savings over the “long term,” which usually means 18 months to 2 years for this group. From a clinical standpoint, however, this period is hardly a long-term timeframe. Clinicians tend to see things along a much longer time horizon of several years or the life of a patient.
Case managers understand this dilemma well. They know employers and insurers need to track and analyze financial results, but they are also clinicians who see the value to the patient over a longer term. The reality is that health care has become increasingly outcome driven. The onus is on case managers and disease managers to speak the languages of both parties and deliver the data that the financial side needs to track costs and savings, while monitoring the health benefit to patients from a clinical standpoint. In addition, outcomes also must be expanded to a total-patient perspective, understanding that other areas are affected by CM/DM initiatives, including pharmacy costs, productivity, and member/patient satisfaction. Lattimer acknowledges that much debate remains over models and standards that can be used to track and benchmark results. “I don’t believe I have seen one study in the last 15 years that you could say everyone in our industry says they are absolutely right, proven 100%,” she commented. “We are always questioning every model and the calculations.”
case managers appreciate the relevance of outcomes in health care, they run the risk of being less valued as members of the health care team. With its strong emphasis on providing quality patient care while controlling costs, CM will remain a vitally important strategy in the future. Furthermore, when CM is coupled with an integrated DM approach, the result can be better, more responsive, and cost-effective care. Seizing the Opportunity Individual case managers have a tremendous opportunity to stay current with developments in DM and to help further an integrated approach to treating the whole patient and promoting maximum health, wellness, and productivity. ❑ Mindy Owen, RN, CRRN, CCM, is a commissioner and former chairwoman of the Commission for Case Manager Certification (CCMC). She is also principal of Phoenix HealthCare Assoc. LLC, a consulting firm specializing in case management, disease management, and managed care development and education in Coral Springs, Fla. Reprint orders: Elsevier Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 579-2838; reprint no. YMCM 173 doi:10.1016/j.casemgr.2004.04.007
Nonetheless, case managers and disease managers must work together as professionals in complementary and collaborative fields to develop the right models. Furthermore, results can be tracked to capture incremental improvements along shorter clinical timeframes and bring more coordination between the clinical and business/finance aspects. “When we say outcomes, we need to look at it in a number of ways. We are able to evaluate things long before 12 to 18 months, factors such as health status, productivity, quality of life, and loss days, among others,” Latimer suggested. As outcomes are devised and tracked, case managers must stand ready to make an important contribution. Unless May/June 2004
TCM 47
by Mindy Owen, RN, CRRN, CCM
A
s case managers have learned, disease management is an important strategy to help meet the health care needs of patients with serious chronic conditions, such as diabetes and cardiovascular disease. Case management (CM) and disease management (DM) have proved to be powerful complementary strategies; while the case manager provides access to the right health care resources in a timely and cost-effective manner, the disease manager works with specific populations to improve patient self-care and education and to maximize the efficacy of treatment.
This fractured approach to DM is neither cost-effective nor focused on patient, provider, or employer satisfaction. “No clinician would tell you that this was the ideal way of providing quality of care for a member, nor would any member tell you that there was a level of satisfaction to having four or five people working with them,” observed Cheri Lattimer, executive vice president of clinical services for Health Integrated, an advanced CM solution company that offers integrated medical and behavioral services to clients. “As we look at our population today, our patients don’t neatly fit into one diagnosis. They are dealing with more than one condition rather than just having, for example, either asthma or congestive heart failure. We need to address the whole patient, not the diseases that the patient is dealing with.” A Holistic, Patient-Centered Approach Clearly, an integrated approach that incorporates CM and DM models is called for. The result will be a more holistic, patient-centered approach that uses managers who are experts in their fields and generalists who can deal with a variety of diseases and health-related issues. Regardless of whether a patient suffers from one chronic condition or several, the point of contact is a CM/DM team that has access to clinical experts. With this integrated approach, the patient works with one disease manager who can address several different clinical conditions. At the same time, the case manager is working to facilitate treatMay/June 2004
TCM 45
the ability of case managers and disease managers to work more collaboratively. This partnership means not only addressing the patient from a medical needs standpoint but behavioral as well. Once again, the objective is to take care of the whole person, not just one aspect or condition.
The aging population will create an increased number of older workers dealing with one or more chronic health conditions that will affect their productivity. ment in a more streamlined environment with effective communication and coordinated comprehensive care. “Take this scenario: Mrs. Jones has five chronic disease states and has been assigned to five different disease managers, all sitting in different departments/companies. And she has a case manager in a sixth company. Think of the administrative costs to have six entities to provide services to the same patient! As they look at the impact of services, return on investment, and value added to the patient, these six companies will speak to the same emergency room visits, clinical visits, hospital stays, and length of stays. And they will also be claiming to save Mrs. Jones and the health plan money,” Lattimer continued.
For more information or to obtain an application to become a certified case manager, contact the Commission for Case Manager Certification at (847) 818-0292 or www.ccmcertification.org.
TCM 46
May/June 2004
“Now consider a scenario that has integrated DM and CM and calls it ‘total patient management’ or ‘care coordination.’ There is one cost, and the integrated team is totally responsible for Mrs. Jones, no matter what the illness or disease. Now when they report back on such factors as ER visits, hospitalizations, and so forth, the results are more accurate when they show improvement in clinical health status and produce member satisfaction,” she added. The integrated approach to DM, as a complement to CM, is becoming increasingly important. The aging population will create an increased number of older workers dealing with one or more chronic health conditions that will affect their productivity. At the same time, employers and health care providers will look for ways to better allocate scarce resources, while meeting the needs of this patient population. Integrating Behavioral Health The prospect of even greater demands being put on the health care system, which is already dealing with spiraling cost inflation, adds a sense of urgency to
For example, patients with more than one chronic health condition may also be dealing with depression, which must be recognized and addressed. Case managers have a responsibility to include depression screening tools in their assessment of this population and raise the awareness of the impact depression has on the total plan of care. Addressing the needs of the whole patient improves the efficacy of treatment, and by treating the depression, patients have a higher likelihood of enrolling and being active participants in DM programs. “The medical and behavioral disease components must be integrated as a whole deliverable if you want to take care of the whole person,” Lattimer added. Lessons of High-Risk Pools The benefits of integrated CM and DM strategies are being reaped within a specific patient population that consumes a disproportionate amount of health care resources— patients in state-sponsored high-risks pools. With pre-existing conditions that make them ineligible for other insurance programs, these individuals enroll in the high-risk pools that now are offered in more than 30 states. Total enrollment in the high-risk pools is about 172,000 people, with claims totaling $1 billion, or roughly $5800 per person. Enrollees in these pools pay high premiums—equivalent to 105% to 200% of the average market premium—and deductibles ranging from $5000 to $10,000. In virtually all states with high-risk pools, insurance companies must pay assessments to make up the deficit between premiums received and claims paid. Thus, many parties—insurance companies, health care providers, patients, state legislatures—have vested interests to control costs while providing
When CM is coupled with an integrated DM approach, the result can be better, more responsive, and cost-effective care. quality care to this population, which is often described as “the sickest of the sick.” By using CM and DM strategies, however, high-risk pools are able to make strides in quality and cost-effective care, including eliminating unnecessary duplication of services, improving patient self-care to promote wellness, and reducing costly ER visits and lengthy hospital stays. Importantly, this approach is not about denial of services but rather allocating the right resources to treat the whole patient in a timely and cost-effective fashion. This goal is the essence of CM and fits well within a DM model that works to bring the patient to the highest level of wellness possible, even when an individual is dealing with several comorbidities. Already these integrated CM/DM approaches are reaping cost savings within the high-risk pools. This experience can serve as an important lesson in other patient populations—including the growing number of older workers— that face more than one chronic health issue. Importance of Outcomes As CM and DM strategies are implemented, results must be tracked to measure the clinical and financial benefits. This means data must be collected and analyzed to determine and quantify improvements in patient health and the cost benefit. One of the challenges in measuring outcomes, however, has been to meet the demands of the clinical side and the financial side. For example, in a managed care environment, the financial side looks for evidence of cost savings over the “long term,” which usually means 18 months to 2 years for this group. From a clinical standpoint, however, this period is hardly a long-term timeframe. Clinicians tend to see things along a much longer time horizon of several years or the life of a patient.
Case managers understand this dilemma well. They know employers and insurers need to track and analyze financial results, but they are also clinicians who see the value to the patient over a longer term. The reality is that health care has become increasingly outcome driven. The onus is on case managers and disease managers to speak the languages of both parties and deliver the data that the financial side needs to track costs and savings, while monitoring the health benefit to patients from a clinical standpoint. In addition, outcomes also must be expanded to a total-patient perspective, understanding that other areas are affected by CM/DM initiatives, including pharmacy costs, productivity, and member/patient satisfaction. Lattimer acknowledges that much debate remains over models and standards that can be used to track and benchmark results. “I don’t believe I have seen one study in the last 15 years that you could say everyone in our industry says they are absolutely right, proven 100%,” she commented. “We are always questioning every model and the calculations.”
case managers appreciate the relevance of outcomes in health care, they run the risk of being less valued as members of the health care team. With its strong emphasis on providing quality patient care while controlling costs, CM will remain a vitally important strategy in the future. Furthermore, when CM is coupled with an integrated DM approach, the result can be better, more responsive, and cost-effective care. Seizing the Opportunity Individual case managers have a tremendous opportunity to stay current with developments in DM and to help further an integrated approach to treating the whole patient and promoting maximum health, wellness, and productivity. ❑ Mindy Owen, RN, CRRN, CCM, is a commissioner and former chairwoman of the Commission for Case Manager Certification (CCMC). She is also principal of Phoenix HealthCare Assoc. LLC, a consulting firm specializing in case management, disease management, and managed care development and education in Coral Springs, Fla. Reprint orders: Elsevier Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 579-2838; reprint no. YMCM 173 doi:10.1016/j.casemgr.2004.04.007
Nonetheless, case managers and disease managers must work together as professionals in complementary and collaborative fields to develop the right models. Furthermore, results can be tracked to capture incremental improvements along shorter clinical timeframes and bring more coordination between the clinical and business/finance aspects. “When we say outcomes, we need to look at it in a number of ways. We are able to evaluate things long before 12 to 18 months, factors such as health status, productivity, quality of life, and loss days, among others,” Latimer suggested. As outcomes are devised and tracked, case managers must stand ready to make an important contribution. Unless May/June 2004
TCM 47