Medical Management

How managing care can improve care and cut costs

Too often, patients are not properly taking medications, following up on care after release from the hospital or correctly managing chronic diseases.

Medical management can help change that, as utilization management nurses and medical case managers work with members to make sure they're getting the most out of their health care benefits, says Dr. Bob Sorrenti, medical director at HealthLink.

"Medical management includes utilization management, in which we look at services to make sure they are medically necessary so the impact of inappropriate medical services can be eliminated," Sorrenti says. "It also includes disease management, putting a focus on people who have high-risk conditions, such as cardiac disease or diabetes, looking at what drives the cost of care and better managing those drivers."

What is medical management?

In a broad sense, through a variety of different types of interventions, medical management addresses the use of services and their appropriateness according to medical standards, the quality of members' experiences as they receive health care, and ultimately, the cost of the medical care. For example, if someone were using the emergency room multiple times in inappropriate ways, a case manager might approach that person about finding a primary care physician. By doing so, the member will save money by paying a lesser co-pay and get a better level of care than that person is getting by frequent use of the ER.

Medical management strives to make sure that physicians are following accepted standards of care and doing the kinds of tests that are appropriate according to those standards. It's not only about saving money; it also helps members avoid being exposed to unnecessary services down the line. As a result, the member has gotten more quality in the level of care, in line with what are the accepted practices in medicine.

How would a utilization manager interact with someone with a chronic condition?

That patient might be impacted in a number of ways. If you were admitted to the hospital, you or your provider would let the utilization management team know. The utilization management nurse would contact your physician and hospital to learn why you were admitted and what the plan of care was going to be.

As your stay in the hospital continued, the UM nurse would make sure you were in the right setting for your needs and that you weren't staying in the hospital beyond the appropriate time.

As your discharge approached, the UM nurse would start thinking about what services you needed after discharge. Do you need to go to a rehabilitation facility or to a skilled nursing facility? Do you need support services at home, such as home health care? Do you understand what your benefits are for these types of care?

The UM nurse would help facilitate the arrangement of those services within your benefits, making sure you were using your network providers and thus minimizing any out-of-pocket expenses. After discharge, a case manager might become involved to look at gaps in your understanding of what you're supposed to be doing and make sure that when you got home, you were following your doctor's directions as to what medication you were supposed to be taking and where you were supposed to be getting your care.

How can medical management help prepare a patient for surgery?

For example, our UM nurses call members who are having elective surgery, both before they go into the hospital and after they leave. The purpose is to ask, 'Are you clear on what's going to happen with your surgery? Do you have your care lined up when you go home from surgery? Do you have someone to take care of you? If you have steps in your house, do you know how the surgery is going to interfere with your ability to do steps?'

After the surgery, the UM nurse would follow up and ask, 'Are you clear on the doctor's instructions? Have you gotten the tests that you were supposed to get? Do you have an appointment to see the doctor? The readmission rates have been reported to run from 7 percent as high as 20 percent in the Medicare population. The key to reducing those rates is to make sure members are following up with their physicians after discharge. Making those phone calls is very important to support members and to make sure they are doing the right thing.

It's not about saying no to someone and denying services; it's about how to help members make sure they are doing the right thing.

How can employers encourage employees to take advantage of medical management?

One thing employers can do is stress to members the importance of engagement with the medical management staff. In the past, people have seen something of an adversarial relationship with medical management people and wanted to keep them at arm's length. If employers can encourage employees to cooperate with the medical management staff that can go a long way to benefiting the member and the plan.

Employers can also stress the importance and value of members actively participating in medical case management. Medical case management often targets members with complicated and extensive care needs. As the case managers help to build the care plan, the member is essential to the success of that plan. The case manager can be of great support and assistance to the member and help them work their way through the complexities of medical care.

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