What Is the Real Objective of Case Management Quality of Care vs. Reduced Costs - Essay Example

26 January 2008 What Is the Real Objective of Case Management Quality of Care vs. Reduced Costs In the past, the health care system has been accused of inadequate quality and high costs. In an effort to improve health care, case management systems have been instituted by health care professionals for the purpose of promoting quality cost-effective outcomes. However, it is questionable whether these systems can offer both quality and low costs. By coordinating the healthcare needs of a patient requiring multiple services from multiple providers, studies of disease management programs have shown that these programs do improve quality by offering interventions such as pre-recorded telephone reminders or home visits by medical professionals (Rand Corporation Study). According to the Rand study, conditions such as diabetes and congestive heart failure (CHF) benefited from case management and reduced costs by decreasing hospital admissions, while patients suffering from depression were more apt to use outpatient services and prescription drugs, increasing costs. Six chronic conditions were analyzed in the study: CHF, coronary artery disease (CAD), diabetes, asthma, depression, and chronic obstructive pulmonary disease (COPD). Improved quality was found in four of the six illnesses, with inconclusive results for asthma and COPD. Long-term health outcomes have not been determined, however, because the study covered only one year. Quality vs. Cost In a one-year study by Michael Long, professor at Wichita State University, geriatric patients who were at least 75 and functionally impaired were randomly assigned to a regular-care group or a case-managed group. The goal was to eliminate the fragmented care that often exists for these patients. Both benefits and costs must be taken into consideration before determining success or failure in such a patient advocacy program (Long). The goal should be set by a team and success determined by whether the goal is met. In Long's study, the case-managed group benefited more than the regular-care group, and improved quality was the result. Cost and quality are sometimes considered opposing factors, but Long considers this too simple an explanation. He recommends a formula: Quality=Benefits - (Risk and Cost), which takes into consideration all the factors involved in case management programs. Limitations of Case Management Programs In a more expanded study, consisting of 46 states examining HMOs and primary care case management (PCCM) programs, the reporting states tended to emphasize utilization results over quality-measure results. In states where many commercial health plans have recently abandoned Medicaid contracts and some rural areas of the United States have been unable to attract health plans, PCCM programs are distinct from capitated managed care plans in that the Medicaid agency purchases health care services as if it were a health plan (Schneider et al). A comparison of quality oversight PCCM programs and health plans serving Medicaid beneficiaries indicates that states with both have fewer expectations for PCCM programs and do not seem to have a distinct goal. At present, the study found that PCCM programs have not as a rule collected performance data, thereby lacking the means to improve quality care. Strengths of Case Management Programs One area in which healthcare costs are accelerated is with the high number of diabetics needing treatment, and case management is highly recommended for glycemic control in these patients. As noted by The Guide to Community Preventive Services online, "Diabetes management is complex and difficult for both patient and healthcare provider, and traditional healthcare delivery methods have not adequately met their needs" (Case Management Interventions). The Guide goes on to say that a systematic review shows case management delivered as part of disease management to be effective in adults with Type 2 diabetes. Managed care strategies for Medicaid populations in Florida, North Carolina, and Oklahoma include enhanced care, and it was found that the recipients in more isolated communities benefit more from extra help, but face-to-face management is difficult to implement, and some Medicaid recipients do not always have access to telephones. Rural case managers are apt to be overextended due to lack of other community resources (Poley, Silberman & Slifkin; Redford). The Gatekeeper Program would alleviate some of the problems that occur in a rural community as would more capitated plans. The result of studying the three states called for more attention to goals and the need for multi-disciplinary teamwork in isolated communities. Role of Gatekeepers The Gatekeeper Program is intended to keep healthcare social workers informed about situations not immediately known to patient advocates. For instance, one apartment manager who was a member of the Elderly Services Gatekeeper Program was able to let the team members know that one of their clients had a long history of substance abuse. Members outside the medical team, for instance, meter readers, bank personnel, fuel dealers, and others in a position to identify problems not immediately obvious to the team increases dramatically the quality of care available (Rascho 1). According to Rascho, 40 per cent of at-risk elderly are apt to be left out because they are alone, and the Gatekeeper Program is one way to bring these clients the social and medical help they need. Troubled adults, Rascho notes, are not likely to self-refer, especially in the case of substance abuse. Future of Case Management Programs Increased need for health care in the twenty-first century has necessitated a restructuring of the system to offer more case management options. With the number of Americans over 65 multiplying more than 10 times from "three million to over 34 million during the twentieth century" (Baugh) the population with significant chronic illness requires a much different care plan than is provided by the acute care system. Case management has developed as one method to meet current health care requirements. It does not generate revenue and cannot be self-funding in the traditional sense. It can, however, produce cost savings through a gatekeeper program and a better understanding of patient needs. A clear definition of case management must be developed with a realistic goal. Utilization review or utilization management is not case management, although a component of case management might be present. Case managers should be part of a care team; they are not a substitute for poorly functioning or weak providers. Works Cited Baugh, Reginald F., and Freeman, Michelle. "Ingredients of a Successful Case Management Program - Case Management." March-April 2003. Physician Executive. 22 January 2008. http://findarticles.com/p/articles/mi_m0843/is_2_29/ai_99129945 "Case Management Interventions are Strongly Recommended to Improve Glycemic Control in Diabetes." 27 December 2002. The Guide to Community Preventive Services. 21 January 2008. http://www.thecommunityguide.org/diabetes/dm-int-case-mgt.pdf Long, Michael J. "Cost Effectiveness of Case Management Programs for the Elderly." Geriatric Times. May/June 2001. 2.3. 22 January 2008. http://www.cmellc.com/geriatrictimes/g010531.html Poley, Stephanie, Silberman, Pam, and Slifkin, Rebecca. "Design of Enhanced Primary Care Case Management Programs Operating in Rural Communities: Lessons Learned from Three States." March 2003. University of North Carolina - Chapel Hill. 21 January 2008. http://www.schsr.unc.edu/research_programs/rural_program/fb_77.pdf Rand Corporation Study. "Disease Management Programs May Improve Quality of Care, but May Not Save Money." 10 December 2007. Rand Corporation. 22 January 2008. http://www.rand.org/news/press/2007/12/10/ Raschko, Ray. "^'Gatekeepers' do the casefinding in Spokane." Aging. (Summer 1990). 22 January 2008. http://findarticles.com/p/articles/mi_m1000/is_n361/ai_9048094/pg_1 Redford, Linda. (Workshop Convener). "International Rural Aging Project." West Virginia University Center on Aging. (8 June 2006). 22 January 2008. http://www.socialworkers.org/practice/standards/sw_case_mgmt.asp Schneider, Eric C., Landon, Bruce E., Tobias, Carol, and Epstein, Arnold M. "Quality Oversight in Medicaid Primary Care Case Management Programs." Health Affairs. 23.6. (2004): 235-42. 22 January 2008. http://content.healthaffairs.org/cgi/content/full/23/6/235 Read More