By Anne Kirby, Chief Compliance Officer & VP of Medical Review Services, Rising Medical Solutions
If we filmed a movie of what Managed Care has looked like over the past couple of decades, it would look much the same now as it did then. Most of our services have been around the block and back (e.g. triage, telephonic case management, field case management, utilization review, bill review), but nothing seems to be truly rejuvenating Managed Care, at least not enough to “move the needle.”
Sure, technology is adding efficiencies and a shiny new coat to many of our services but, if the processes are the same, we’re merely getting better and faster at an old approach. For instance, so many of our processes and metrics remain transaction-based – in bill review, it’s the number of bills reviewed; in utilization review it’s the number of decisions made; in telephonic case management, it’s the number of tasks completed or cases closed. You see, transactions may be achieved faster with technology, but nothing is really tying together all of these processes. Even when there’s talk of the purported “integrated model” where gaps are shored up between services, the discussions revolve around the linking of software systems, not around truly improving care management. Up until now, we’ve focused on Managed Care in a very mechanical way, leaving behind the most important part of the equation: creating excellent outcomes.
In order to make effective Managed Care decisions something must be added into the mix to, not only integrate our processes, but unify and drive the entire strategy.
Breaking Out of the Managed Care Bubble
Most of us are familiar with the old adage that the workers’ compensation industry drives by only looking through the rear view mirror. Indeed, this is how rates are calculated and underwriting models are developed. But if we’re only looking back, when do we start looking forward? To date, the Managed Care industry has only helped to perpetuate this necessary but limiting approach. We must no longer drive looking through the rear view mirror, but rather on the real terrain ahead, which doesn’t always match the road behind us.
If I had to boil down the purpose of Managed Care companies in the ideal world, it would be to help payers get to the ultimate cost of each claim in a faster and predictable manner. So what’s the solution? What’s the unified approach? What might be new under the sun in Managed Care?
Case Management 2.0
The solution starts with a new spin on Case Management. In the 90’s, payers became focused on its service costs and began delegating only very specific cases and tasks to case managers. This can control management costs, but often the referral is happening too late in the game and cases have already become problematic. Sure, there’s a place for task-based management, but who’s really “minding the store” while all these disjointed, micro-tasks are being completed?
The power of case management is getting in at the beginning and identifying problem cases before they become problems. But what if we could do this in a more effective, cost-conscious way than in the past?
Matching Technology with Talent
Here’s where technology can really help us do better versus make us better at old approaches. We can now enlist case “scoring” analytics almost at the onset of each injury that utilize claim predictors (i.e. age, BMI, previous traumatic event, geographic location) and generate actionable dashboards to identify which cases should be placed on low or high risk treatment plans.
This type of claims intelligence allows us to: 1) filter low risk cases back into the analytics system for further monitoring, and 2) proactively dispatch case managers only to those cases that need intervention, as demonstrated by cost, indicator (i.e. opioid usage) or status. Once deployed, we need to stop delegating tasks and really let a case manager manage the medical aspects of the case, providing the level of guidance necessary to generate the best treatment and cost outcomes.
Recognizing and Beating the Hurdles
Sounds like a lot of upside, so what’s the issue, why isn’t everyone onboard with this “new” way of managing care. First, it requires a strong client relationship. Managed Care organizations must have trusting, consultative customer relationships because customers must be willing to share their claims data. In this world of switching vendors every year or two – this is harder than it used to be. The soft market has perpetuated this model and buying on price does not promote the development of long-term relationships.
Second, limited customer IT resources may hinder the sharing of claims data, even if the claims department is on board. Third, Managed Care organizations must be able to provide reporting that demonstrates tangible value in this case management-driven approach.
Fourth, although there is a place for task-based assignments in case management, payer organizations must adopt a more balanced approach. The problem with a program that uses only task-based assessments is that eventually everyone forgets to look at the big picture.
Moving beyond these hurdles will help us activate a focus that spots potential problems before they become actual problems, closes or settles cases faster and saves money. All with an eye on driving payers towards their ultimate cost of a claim more rapidly and in a predictable manner.
About Anne Kirby
With 30-plus years of industry expertise, Anne Kirby heads Rising Medical Solutions’ Compliance and Medical Review units – overseeing quality management and legal compliance initiatives, as well as the delivery of Utilization Management and Care Management services. Under Kirby’s leadership, Rising has received its URAC accreditation, obtained numerous state certifications, passed mandatory state audits of Rising’s services and developed innovative technologies to enhance service delivery.
Prior to Rising, Kirby co-founded BlueMat Solutions, a consulting firm servicing the healthcare and workers’ comp markets. She has been instrumental in developing multiple case management platforms and technology tools for case managers and utilization review nurses. Earlier in her career, Kirby worked for 22 years with Concentra Managed Care in a variety of roles, including: Regional Vice President, Vice President of Product Development and Vice President of Marketing and Sales.
Throughout her career, Kirby has advised employers, insurers, managed care companies and regulatory bodies in various states on topics related to managed care. She has developed a national database of rules for utilization review and case management service delivery. At numerous industry events throughout the country, she has served as an expert speaker and has participated on several boards, including: Workers’ Compensation Research Institute (WCRI) Core Funders, Risk and Insurance Customer Advisory, and the Walpole Area Visiting Nurse Association.
Kirby holds a Bachelor of Science in Nursing from St. Louis University and a Bachelor of Arts from Boston College.
About Rising Medical Solutions
Rising Medical Solutions (Rising) is a national medical-financial solutions organization that provides medical cost containment, care management and financial management services to the workers’ compensation, auto, liability and group health markets.
Based in Chicago, Illinois, Rising started as a two-person team and is now one of the fastest growing private enterprises in America, as ranked by Inc. magazine and the Private Company Index (PCI). To learn more, visit: www.risingms.com.