Case Management: Balancing Care & Cost

Executive Summary

As the constant evolution of the healthcare industry continues to drive new solutions to address age-old challenges, the ultimate goals remain the same – reduce employers’ impact of claims and deliver improved care to injured workers to enhance their quality of life at work and at home.

A return to case management, the root of workers’ compensation, offers unparalleled – and often unrealized – results when adapted to claims management. Executing case management services at the right time during the claims process, combined with information and real-time technology to combat delays, can increase efficiency across the healthcare management process and lead to better outcomes for all parties involved.

Introduction

Over time, case management has developed a negative stigma, causing employers to often associate it with excessive dollar signs in the context of the claims continuum. It is commonly misunderstood as a service that generally employs one of two techniques: one, assigning a nurse to attend an injured worker’s doctor’s visits, or two, a program add-on introduced after a case has been open for more than six months racking up even more spend. In actuality, case management is synonymous with savings – including decreasing inappropriate care and reducing hospital readmissions – when utilized effectively.

Timing is Everything

When case management is implemented for a claim is crucial to the injured worker’s outcome and their employer’s bottom line. Today, case management should not be strictly reserved for the highest-cost patients, which only constitute between 1-5% of most employers’ populations (IMS Institute for Healthcare Informatics).

Inaccurate assignment of case management has contributed to the widely-accepted reputation labeling such services as inevitable cost drivers. Time delays in referring a claim to case management have been found to increase medical costs by up to 60%, according to CorVel’s book of business.

An effective case management program tackles cost drivers at every stage of a work-related injury – including before an injured worker checks in for a doctor’s appointment. A proactive approach to medical management can lead to a medical only determination, significantly saving employers’ dollars. From initial Advocacy 24/7 to appointment follow-ups, case managers help guide the injured worker through the episode of care, making for the most effective, tailored treatment program.

Address the Challenge Sooner

According to the U.S. Bureau of Labor Statistics, there were nearly 3 million nonfatal workplace injuries and illnesses reported in 2012. Employers across the country are paying for those claims. While not all workplace injuries and illnesses require a case manager, in many instances case management may have been able to prevent unnecessary medical spend.

Significant savings can be achieved when case management is utilized in a timely manner rather than added months after a case has been open. Taking a proactive stance towards medical management during the claims process can empower an injured worker’s return to work plan to avoid stagnation and instead reach an accurate maximum medical improvement status.

Upfront costs can yield long-term savings. Effective case management can efficiently navigate care, helping to avoid additional doctors’ visits, medical interventions and prescriptions that may arise later in the claims process but are not obvious during the initial stages after a workplace injury has occurred. Up-to-the-minute, comprehensive information enables adjusters to make better decisions. Employers can be confident about these initial investments with a program backed by information. A case management program that is resourceful in both injured worker data and advocacy can decrease costs for employers down the road.

Advocacy 24/7

Claims today require immediate response. While some claims models may promote placing onsite case managers within network clinics increases patient engagement, results can be further improved by preventing patients from attending unnecessary clinic visits.

To combat costs associated with the delay or incorrect assignment of case management, an ideal claims program aims to initiate medical management at the onset of an incident or injury. Immediate Advocacy 24/7 is engaged via a phone call in which injured employees can speak with a registered nurse who will evaluate the nature of the incident or injury and determine the employee’s immediate medical needs. The Advocacy 24/7 nurse’s experience provides a professional medical opinion, which can possibly determine that case management is not necessary for the reported incident or injury.

By addressing the case when it first occurs, this immediate introduction to the first touch point of case management enables injured workers to receive quick and systematic intervention, revealing a more accurate depiction of the reality of the total exposure. Many times this can prevent a minor injury from becoming an expensive claim and avoiding an unnecessary emergency room visit.

Process and Continuous Claims Management

Throughout the process, the case manager coordinates with the treating provider and injured worker, and will make recommendations to the adjuster to continually modify the treatment plan for the best possible outcomes. Sophisticated systems can provide a remedy for expensive delays within the process and proactively work toward return to work with actionable data and by issuing alerts for follow-ups to appointments and flagging cases as additional intervention is needed.

In addition, case managers can consult clinical protocols including ODG, MD and ACOEM guidelines. Based on the diagnosis and known comorbidities, guidelines are established for treatment as well as return to work expectations. As cases approach designated benchmarks and thresholds outlined by the employer, the case manager addresses and adjusts the file accordingly.

The presence of a case manager not only empowers and supports the injured worker, but also provides a springboard to other resources. Case managers build and maintain a relationship of trust, which can often reveal facets of the injured worker’s condition that help determine their recommendations for treatment. If an injured worker exhibits signs of depression or deterioration, or has multiple comorbidities which may inhibit improvement, the case manager has first-hand insight to identify these triggers for additional intervention management and can notify the adjuster through case notes.

In the event that an injured worker is recognized to potentially benefit from other programs to enhance their outcomes, the adjuster will coordinate appropriate treatment. For instance, the adjuster may initiate their participation in an interdisciplinary clinical pain management program. Serving as a navigator during the episode of care, the case manager can consult other care professionals through an integrated approach to benefit health outcomes while ultimately lowering employer medical spend.

The Power of Case Manager Relationships

A female patient was undergoing treatment after sustaining a shattered left femur and knee from a car accident while on duty. The claim was identified as complex and flagged when recovery stalled.

Because of the close relationship that the case manager maintained with the patient, the case manager was able to identify she was struggling with pain and depression. Her pre-existing depression, combined with the pain and depression she experienced as a result of her injury, heavily influenced her life and the injured worker told the case manager she did not wish to return to work. Further review of the case file demonstrated the patient’s history of problematic use of prescription drugs.

The case manager recorded the observations in the case notes and the adjuster assigned a team to conduct a clinical pain management evaluation. The team recommended that in addition to her current physical therapy program, the patient undergoes psychological treatment, which consisted of a wellness intervention and cognitive behavior therapy, helping the patient shift her thoughts toward recovery rather than her pain.

Once the patient’s behavior and attitude toward her injury changed, she was able to make progress in her physical recovery. Within three months the patient was able to return to work in a modified position and eventually returned to full duty.

People First

Today, technology drives healthcare management. In a world of instant gratification, stacks of hard-copy documents are not an efficient means of managing workflows. Such traditional forms of communication lead to expensive delays – delaying treatment, claim resolution, and ultimately claim closure.

Industry needs require systems to accommodate real-time information to drive claims outcomes and return to work. Mobile technology aids this effort. Placing real-time tools into the hands of case managers can ensure injured workers are approved for return to work as soon as the physician’s approval is received, not hours or days later. Timelines can be streamlined and management can improve with immediate Advocacy 24/7, assignment, and status updates.