Medical Management

How managing care can improve care and cut costs

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

With medical management, utilization management nurses and medical case managers work with members to ensure they get the most out of their health care benefits, says Dr. Robert Sorrenti, medical director at HealthLink.

"Medical management includes utilization management, in which we look at services to make sure they are medically necessary so 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, better managing drivers of the cost of care."

What is medical management?

In a broad sense, 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 care. For example, if someone uses the emergency room multiple times in inappropriate ways, a case manager might approach that person about finding a primary care physician.

Medical management strives to make sure physicians are following accepted standards of care and doing appropriate tests. It's not only about saving money; it helps members avoid being exposed to unnecessary services.

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

That patient might be impacted in a number of ways. If you're 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's the plan of care.

As your hospital stay continues, the UM nurse makes sure you are in the right setting for your needs and that you aren't staying in the hospital too long.

As your discharge approaches, the UM nurse considers what services you need after discharge. Do you need to go to a rehabilitation facility or skilled nursing facility? Do you need support services at home? Do you understand what your benefits are for these types of care?

The UM nurse helps arrange for those services within your benefits, making sure you use network providers and minimize out-of-pocket expenses.

After discharge, a case manager might look for gaps in your understanding of what you're supposed to be doing and make sure you follow your doctor's directions for medication and additional care.

How can medical management help prepare a patient for surgery?

UM nurses might call members who are having elective surgery, before they go into the hospital and after they leave. They'll ask, 'Are you clear on what's going to happen with your surgery? Do you have your care lined up when you go home? Do you have someone to take care of you?

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?'

Readmission rates have been reported to run from 7 percent to as high as 20 percent in the Medicare population. The key to reducing those rates is making sure members follow up with their physicians after discharge.

It's not about saying no and denying services; it's about helping members do the right thing.

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

Employers can stress the importance of engagement with the medical management staff. In the past, people have wanted to keep medical management at arm's length. If employers can encourage employees to cooperate, it can go a long way to benefiting both the member and the plan.

Employers also should stress the value of members actively participating in medical case management, which often targets those with complicated and extensive care needs. As the case managers help build the care plan, the member is essential to its success.

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