By Lief G. Goodson, CEO, Bunch CareSolutions, A Xerox Company
Think for a moment about a special nurse that may have provided services to you or your loved one. Nurses have a remarkable ability to empathize, educate and coach someone back to health. Within the workers’ compensation space, nurse case managers also serve as liaisons and care navigators coordinating medical services and resources in an intricate health care maze that continues to become progressively more complicated for injured workers, employers and payers. Yet, some claims require more than nurse case management generalists to successfully maneuver the myriad of highly-complex treatment regimens, multifaceted interactions and broad spectrum of services across the care continuum, especially in areas such as surgery and medication management.
Experienced nurse case managers with advanced training in surgery and polypharmacy are becoming more important in the framework for managing complex, high-dollar claims. In an industry where 20 percent of the claims drive 80 percent of the costs, leveraging clinical expertise and technologies to streamline workflows and medical interventions is extremely important. Some of the key factors driving the demand for clinical specialization include: increasing sophistication in medical treatments and advancing scientific technologies, innovative data and communication systems, shifting population demographics and risk stratification (an aging workforce and increasing co morbidities), as well as a rapidly changing health care environment. As a result of these factors, and to satisfy the needs of our clients, we began offering highly-specialized niche services within the broader scope of case management.
Clinical specialization provides targeted, episodic care specifically focused on resolving surgical, pharmacy or legacy claims to achieve greater cost efficiencies without sacrificing clinical oversight, patient advocacy or quality outcomes. We have seen upward demand for clinical specialization from clients with highly-customized risk management programs, including those leveraging our predictive analytics to allocate clinical resources throughout the progression of care management. With predictive modeling, triggers for specialized nursing resources can be deployed at critical junctures in the care process to move a complex claim towards final resolution for maximum medical and financial impact.
Clinical specialization is not intended to limit or supplant general nurse case management activities, but rather complement them. A surgery nurse, specializing in pre- and post-operative services and discharge planning, for example, will be more proficient in understanding the latest surgical technologies, including complex surgical procedures, hardware and medical implants. Utilizing a nurse resource with surgical competencies also enhances cost containment opportunities: capitalizing on pre-op and post-op education opportunities, instructing the patient on the proper use of prescription medications and drug interactions, examining the network status of both the treating provider and the surgical facility, channeling surgical procedures to outcomes-based providers and network facilities (when and where appropriate) and assisting the adjuster with reserving and cost projections.
Similarly, a pharmacy-focused nurse can bring an additional level of clinical acumen to medication management. Primary responsibilities include: managing the pharmacy component of a claim file, overseeing prescription authorizations, performing routine drug reviews, determining settlement and Medicare Set Aside cost projections and providing comprehensive medication profile analyses. For some clients, the pharmacy-focused nurse also accesses the PBM’s portal to identify claims that would benefit from peer review, drug utilization review or field case management services for increased patient safety and reduced pharmacy spend.
With clinical specialization, consultative, task-assigned services tackle high cost surgeries, polypharmacy and lingering aged claims. Services are customized according to a client’s pain points and incorporate evolving capabilities and clinical pathways, creating information-rich environments, tighter fiduciary controls and more consistent medical and financial outcomes.
Clients will be paying for the latest capabilities and technologies applied in the care and healing of injured workers. Therefore, it is essential to create value by leveraging innovation, analytics and new capabilities like clinical specialization. In Part 2, we will explore specific metrics utilized when calculating the ROI of clinical specialization.
About Lief G. Goodson
Lief G. Goodson joined Bunch CareSolutions as the company’s chief operating officer in 1996. With more than 25 years of executive management experience, Goodson has held leadership positions in corporations and industries that span the globe. Throughout his tenure, he has strengthened Bunch CareSolutions’ infrastructure, overseeing the expansion of facilities, staff and service offerings from a small, regional field case management company to a premier national disability management company. As architect of the company’s technology plan, he was responsible for the implementation of the paperless and thin-client technologies employed today. With a profound understanding of analytics and technology, Goodson has been a vital proponent in the development of the company’s data systems, reporting capabilities and predictive modeling applications. He continues to focus on strategic planning, innovation and quality assurance in all service areas. In addition to his leadership role at Bunch CareSolutions, Goodson also heads up workers’ compensation clinical services capabilities for Xerox Services.
About Bunch CareSolutions, A Xerox Company
Bunch CareSolutions is a national medical management company based in Lakeland, Florida. The company operates exclusively in the workers’ compensation industry as a full service, managed care firm. Since its founding in 1988, Bunch CareSolutions has consistently grown in size, scope of services and standards of excellence. It has done so without compromising its clinical focus or mission of “making the world a better place—one life at time.” To learn more about our services, visit www.bunchcare.com.