What is Care Management?

As discussed in URAC’s 2005 Industry Report, national trends reveal a medical management industry in a dynamic period of transition. Its core: UM, CM, and DM remain valuable and viable and technology is dramatically changing the industry, adding tools that will improve the integration of care management service delivery, enhance care coordination, increase the use of predictive modeling and targeted intervention capabilities, and enhance consumer-directed health care. Care management organizations are now providing more customized management solutions based on purchaser needs. While advances in technology are changing the industry, adding tools that will improve both efficiency and effectiveness, many of the services remain labor intensive and telephonically based and still require the decision-making skill of medical professionals such as registered nurses (RNs) and physicians (MDs), while evidence-based medicine remains the bedrock of care management decision making.

Responding to the regulatory, provider and consumer push-back on aggressive managed care tactics of the 1980s and early 1990s, the care management industry has introduced care coordination as a general strategy. Rather than allow the industry to be defined by “denials,” it has become an industry that defines itself by “care.”

This paper on care management focuses on medical management practices, but pharmacy benefit management practices include many of the same techniques as described above and similar practices, such as drug utilization management, medication therapy management, which are discussed in a separate paper.

Utilization Management

URAC DEFINITION: Utilization Management is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan; sometimes called “utilization review.”

As part of the 2005 research findings, URAC detected that the trend towards integration of medical management services continues. But at the same time, traditional UM functions such as precertification, concurrent review and retrospective reviews are foundational elements that continue to be employed. With rising medical costs again a major market issue, companies are under a high degree of pressure to control costs through traditional UM interventions. However, in many cases, advances in technology, including the use of predictive modeling and other methods of data analysis, are creating opportunities for UM to be targeted to where they are likely to yield the greatest impact.

Case Management

URAC DEFINITION: Case management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet a consumer’s health needs through communication and available resources to promote high quality, cost-effective outcomes.

Case management has been practiced since the early 1900s starting with public health service providers, then broadening to hospitals, and to insurance companies who began to employ nurses and social workers to assist with the coordination of care for patients who suffered complex injuries requiring multidisciplinary intervention. This evolution has continued to encompass the coordination of services to clients in categorically defined groups (e.g., low income, mentally ill, frail elderly) to ensure the patient's needs are met appropriately (advocacy) and proper use of resources are maintained.

In general, the purpose of case management is to coordinate, facilitate and follow over time a client's use of an array of health and social services. Insurance-based case management is a labor-intensive activity that typically is provided telephonically. In recent years, the importance of CM services has expanded as a fundamental building block to the care management system. Since CM is an intensive service, selection of which cases are to be managed is quite important.

Disease Management

URAC DEFINITION: Disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management supports the physician or practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health. Disease management components include: population identification processes; evidence-based practice guidelines; collaborative practice models to include physician and support-service providers; patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance); process and outcomes measurement, evaluation, and management; routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers, and practice profiling. (Source: Disease Management Association of America)

Traditionally, disease management has focused on the following chronic diseases: heart disease, heart failure, diabetes, pulmonary disease, and asthma. Disease management programs generally are offered telephonically, involving interaction with a trained nursing professional, and require an extended series of interactions, including a strong educational element. Internet programs, print literature, and face-to-face trainings are also utilized by DM programs, but to a lesser extent. Patients are expected to play an active role in managing their diseases. Over time, the industry has moved away from single disease state focus toward a whole person model in which all the diseases a patient has are managed by a single disease management program.

In the United States approximately 10 percent of patients account for 70 percent of overall health care spending. Typically due to chronic or complex medical conditions. In addition, research shows significant gaps between best medical practices that follow evidence-based treatment guidelines and the care many patients—especially those with chronic conditions—actually receive (Center for Studying Health System Change; Issue Brief No. 69, October 2003). These well-established facts have driven the development of DM programs, which typically identify a population of patients with a specific chronic condition, particularly those such as asthma and diabetes, where well-established, evidence-based treatment guidelines exist and patient self-care and compliance are important factors in managing the condition. Disease management interventions include sending patients educational materials about their condition and reminding them to adhere to prescribed medications or seek a preventive screening. Interventions also often include educational efforts, treatment guidelines and reminders aimed at physicians and other providers.

Health Call Center

URAC DEFINITION: A clinical Health Call Center is an organization providing triage and health information services to the public when conducted by telephone, via web site or using other electronic means.

Health Call Centers can be independent care management vendors, but more often are units within an insurance company or a hospital system. Interestingly, clinical and administrative HCC functions remain separate operations. The customer service administrative functions include membership eligibility questions, ordering ID cards, locating in-network providers. HCCs are beginning to move beyond in-bound nurse telephone triage services to include out-bound telephone CM and DM services. HCCs also often make health content available to the patient telephonically. A HCC can often cue hundreds of different educational modules on the phone system to play for the patient. The patient can also access information directly via the Internet or self-service phone.

The most common staffing model for clinical HCCs is for in-bound calls to first be taken by trained health services representatives who are not medical personnel. These representatives take demographic information, then transfer the caller and information to an RN who uses clinical protocols/algorithms to guide the advice given.

Independent Review

URAC DEFINITION: Independent Review is a process, independent of all affected parties, to determine whether a health care service is medically necessary and medically appropriate or experimental/investigational. Independent review typically (but not always) occurs after all appeal mechanisms available within the health benefits plan have been exhausted. Independent review may be voluntary or mandated by law.

Traditionally, independent review has been performed by peer review organizations (PROs), now called quality improvement organizations (QIOs), which have been operating for more than 30 years. In the past decade, independent peer review has moved beyond Medicare and Medicaid to serve commercial insurers as IROs. Moreover, the recent Department of Labor regulations have created a demand for specialty review services within a shorter turnaround time. Typically, IROs have a small full-time staff and contract with hundreds of consultant peer-reviewers.

During the coming years, as care management becomes more customized and as consumer-directed health care takes hold, there are likely to be more cases arising from member/consumer desire for increased accountability. As a result, the number of coverage cases going to external review may increase. However, the number of medical necessity cases may decrease as medical management companies focus more on high cost UM cases and physician practitioners become more accustomed to evidence-based medicine clinical decision support tools in the ambulatory setting.

For more information about case management, URAC suggests the Case Management Society of America

For more information about disease management, URAC suggests the Disease Management Association of America

For more information about independent review, URAC suggests the National Association of Independent Review Organizations

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