Aligning Managed Care Management - Essay Example

Aligning Managed Care Case Management: Manage care refers to the organization of care management and delivery with the intention of balancing access, care quality as well as the cost aspect. It employs strategies such as utilization management, intensive case management, selection of providers and methods of containing costs (CSAT, 1995d). Even though many providers especially in the public sector are not comfortable with the concept of managed care, most of them are actually working to similar ends through similar strategies as managed care organizations (MCOs). Most providers treating substance abuse for instance have for decades worked in the framework of managed care i.e. through utilization data and development of the care continuum. Most substance abuse treating providers, especially those using case management have for a long time appreciated the need for connecting various services in order to satisfy client needs. Funding Case Management in a Managed Care World. Case management is a promising adjunct to provision of service when it comes to managing and treating substance abuse. But its efficacy must be backed by adequate empirical data; critical decision makers must understand that it is an integral part of the treatment process so as to incorporate it into the structure for funding. This is a very important concern especially in states that chose to deliver health services via managed Medicaid HMOs as well as individuals receiving services through Medicaid. Containing cost whilst delivering healthcare gives administrators and case managers the chances of demonstrating the utility of case management. Patients with chronic illnesses for instance may be forced to out of their residents to the communities for providers to believe their readiness. Case management becomes very apt for such scenarios as the clients are then provided with the support required in aiding their smooth transition. Case management can also be quite helpful when it comes to preventing relapse and offering aftercare thus averting the requirement for costly services like seeking inpatient treatment. Tools of managed care such as clinical pathways standardization of assessments and protocols for treatment can usefully utilized in the context of case management. A major challenge accompanies the tailoring service delivery for the unique needs of the specific clients as well as avoiding “Cookie Cutter” services. The use of managed care tools can significantly increase the appeal of case management especially to program administrators working in capitated and other environments of shared risks. The main test is developing comprehensive case management systems within the framework of managed care that are flexible and have the much needed resources to show eventual cut in costs. That way MCO will be able to solidly justify why case management as a service should be reimbursed. Who Decides? Deciding whether to include case management in entire continuum of service delivery lies at the program or primary funding level. As most public sector providers embrace managed care, they must appreciate case management as being critical in effective service delivery and communicate just the same to program financiers. In an event where the primary financiers (mostly state agencies) expect specific outcomes beyond sobriety and cost containment, then it is the responsibility of administrators to formulate ways for measuring such outcomes. Undertaking scientifically valid outcomes research out of the jurisdiction of many providers. However, providers could market case management to program funders if they can be able to measure every effort that helps the client i.e. client run support groupings, drop-in centres as well as Compeer programs where volunteers offer support to the clients. Maintenance of proper records will help managed care providers in determining just exactly what they are providing and what makes up case management. Funding Methods. The fact that funding for public programs for treating substance abuse attracts many players poses a complex challenge most program administrators. This is particularly due to the fact that every stream of funding will have unique conditions and requirements for eligibility as well as reporting which in many instances are different from requirements by other agencies that support operations of the programs. This is true with case management as funds have traditionally come from a multiplicity of sources. The sources include: Grants by Federal agencies Medicaid, this in some cases includes options for non-Medicaid services such as the Medicaid rehabilitation program. Medicare and Supplemental Security Income (SSI) for disable clients. Migrant Health funds Private foundations and funds like Unite Way State and local tax Private insurance programs The incongruent mandates of the disparate financiers have often aggravated fragmentation in the system and provision of services. An emerging strategy for melding service delivery and ensuring continuity of care comes with integrating the various streams of funding. In some states, Medicaid and managed care for instance, has been used to catalyse the blending of funding streams, especially in the models of full capitation. With the increasing freedom for states to expend Medicaid dollars in the manners deemed most fit for them, the flexibility in terms of services provided at the program levels also increases. Programs that account for funds in terms of positive consumer outcomes are better placed to structure their services in response to unique needs by specific clients as opposed to the dictates of financiers who are separated from the level of service delivery. Managed care is increasingly being used as a highway for the integration of funding sources and encouraging co-operation among healthcare service providers. Most managed care organisations for instance only contract integrated providers networks who; Offer the full range of services Extend their area of coverage to wide geographical locations thus increasing the enrolment potential whilst sharing the financial risks among more providers. Maximise their efficiency in areas like management information systems. When service providers are organised as such, the administrative service organizations are more engaged to cover more business assignments for the entire network. Approaches for blended funding i.e. specifically those granting providers the freedom of making clinical decisions while at the same time holding them responsible for fiscal accountability can promote case management as an integral function in the modern treatment of substance abuse. Capitation based on the real treatment costs as well as “stop-loss” clauses covering contingencies such as reimbursement longer treatments that are unanticipated could significantly help in satisfying the desire by providers for more flexibility and financiers requirement for fiscal accountability. The services for treating substance abuse are often conceived differently depending on the overreaching model of healthcare delivery preferred by states or MCOs that are contracted to offer the services. At the moment, carve-in and carve-out models are the two most implemented. Carve-in Models. The carve-in model combines physical healthcare services (traditional) and behavioural (mental health and substance abuse treatment) healthcare services. This model is often preferred when it comes to managing Medicaid populations by states. Even though service purchases may opt the carve-in model, MCOs frequently chose to carve out especially with behavioural healthcare by contracting. This is necessitated by the fact that behavioural healthcare provision has been found to be a very expensive cost centre within the integrated model of managed care provision. Providers are generally attracted to the carve-in model since most clients with mental illnesses and problems of substance abuse also come with significant physical injuries. Integration of the two at the same time emphasizes the idea that because the body and brain are just parts in one system, mental conditions and substance abuse problems are bona fide health concerns. It should be noted that in this model, case management takes the nature of an administrative function involving clinical oversight as well as activities like review of utilization and prior authorization procedures. The role of case manager is vested in the primary care physician who performs an assessment of all the services required by a client and refers him/her to the network of providers that provide the specialty services. This is the typical case in events where the physician is not well equipped to offer the unique case management functions as required by the specific patient successfully. There are two important setbacks to this model of providing behavioural healthcare that must be appreciated. Firstly, primary healthcare physicians may under diagnose issues of substance abuse especially in special populations like women and elderly persons where depression is commonly diagnosed but seldom associated with abuse of substance. Knowledge deficits or the desire to cut costs especially on the part of clients may also encourage underutilization of available services with most being left out on essential care services. Secondly the entire course and total costs for treating behavioural problems are not easily predictable as compared to issues of physical health, establishing firm enrolment and or capitation rates is almost impossible. When the rates are strikingly low, then the concern of inadequate treatment or exclusion of individuals with most need for the high cost prolonged care services e.g. those requiring residential management increases. Skimming is another problem of concern particularly when services are subcontracted. But this situation provides an opportunity for cost-shifting difficult customers to those subcontractors receiving only a fraction of the whole rate of capitation. This not only has the challenge of reduced availability of funds for providing adequate treatment but also strains the resources on the part of subcontractors significantly. Carve-outs Read More