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At a manufacturing firm, an employee is off work due to a job-related injury. He also has high blood pressure and elevated cholesterol, which pose a health risk--even though these conditions are unrelated to the workers' compensation claim and outside the scope of treatment for the industrial injury.

To address these needs, employers and other plan sponsors, such as multiemployer trusts, typically offer a variety of healthcare management and wellness services. Often, these services are provided by a number of different vendors.

It's not enough for an employer to offer an array of programs and expect its employees will somehow get the services and support they need. Without systematic coordination, there is no guarantee that employees will automatically receive the right services they need at the right time from the right professional. What's required is greater integration among vendors with seamless referrals from one program to the next.

"You have to look at the entire individual, not just the claim or the benefit program. For example, you may have an obese employee who has an injured back, which results in a workers' compensation claim. As you manage that claim and the medical treatment of the injury, you cannot ignore the fact that this person is seriously overweight," said Dorothy C. Fairnot, Southeast area manager for MedInsight Inc., a workers' compensation managed care organization.

"Unless the underlying medical conditions, which may have contributed to the injury, are addressed, they will affect a person's recovery and ability to work," added Fairnot, who is also a commissioner with the Commission for Case Manager Certification, the first and largest nationally accredited organization that certifies case managers.

Taking an integrated approach means shifting the focus away from specific programs and emphasizing the health needs of employees. These needs will change over time with improvement or deterioration in health status. Other factors also impact employees' health and productivity, including behavioral health issues, personal or family problems, and even workplace issues.

"The successful case management and disease management programs of the future will incorporate such concepts as job satisfaction, the person's social circumstances, satisfaction with life and so forth. In other words, the total person is much more than his or her immediate disease state," said Thomas Emerick, president of Emerick Consulting LLC of Fayetteville, Ark. As a former vice president of benefit design for massive retailer Wal-Mart Stores Inc., Emerick has experience managing health, medical and disability programs.

Addressing the needs of the "total person" calls for better integration of employee assistance programs into the health and productivity mix, he said.

"The objective is to understand the employee better, the issues that he or she is facing, and the complexity of his or her life. That has the potential to assist the person hugely with health and productivity," he added.

Emerick gave the example of certain types of health problems (e.g., a back injury) that could be nearly identical in two employees. One employee ceases being a productive worker from the onset of the problem, yet the other barely misses a day of work. The difference in the employees' productivity may be rooted in general job dissatisfaction, conflict with a boss or a personal problem. It may also be due to the clinical medical factors. Services such as case management and EAP in coordination could help uncover and address the roots of the problem.

BETTER INTEGRATION AMONG VENDORS

Integrating services provided by multiple vendors across the health and wellness spectrum makes sense. Achieving that goal--with information shared and referrals made among as many as 10, 15 or more vendors--is often easier said than done.

The obstacles range from siloed programs to competition among service providers, particularly if referrals mean a drop in one program's headcount and a gain in another.

Despite these challenges, employers and other plan sponsors are taking steps to improve the cost-effectiveness and integration of the programs offered to ensure that the health and wellness of the individuals served are paramount.

Employers are also looking for greater coordination of services in order to achieve specific goals, including:

-- Improving employee awareness, knowledge and utilization of available programs and services

-- Avoiding duplication of services, particularly among multiple vendors

-- Facilitating seamless handoffs and referrals among vendors

-- Assisting employees to access the right services at the right time

-- Maintaining or improving quality of services delivery to employees

-- Accessing the professional with the appropriate knowledge, skills and abilities

One way to encourage better coordination is to bring service providers together in vendor summits, or integration summits as they are also called. These meetings, which may be held telephonically or in person, allow employers and other plan sponsors to communicate with multiple vendors at once. The message being delivered is that in order to improve quality and manage costs, vendors must collaborate more and coordinate service delivery.

As summits become more common, employers say, vendors become willing participants at the table. They understand that better coordination can lead to measurable improvements in clinical outcomes, employee productivity and satisfaction, and utilization of the services--all of which benefit the company's return on investment to offset the cost of offering these programs.

This can only happen, however, with a system in place to make referrals and hand off individuals from one program to the next. These junctures are critical points where breakdowns can occur. This calls for a clearly defined, standardized approach for all vendors to follow, with procedures for how and when to make a referral and whom to contact.

AN EXAMPLE VS. REALITY

An individual with heart disease and high blood pressure receives disease management and health coaching to improve their adherence to a physician's plan for diet, exercise and medication. The person then suffers a heart attack and is hospitalized.

Upon admission, utilization management begins reviewing the medical necessity of inpatient services, as well as the appropriateness of discharge planning. This review results in a referral for case management services. After the acute episode is over and the person achieves a level of clinical improvement, she is then discharged and, as her condition improves further, eventually returns to the disease management/health coaching program.

Although this transition from program to program is the ideal, it's not always what happens in the real world. Vendors may be reluctant to share data or refer patients because of the way they are compensated; for example, retaining as many enrolled employees as possible in a particular program due to the method of payment that is based on number of enrolled participants. Other possible reasons range from a lack of communication to incompatible systems.

Ultimately, it becomes the role of the employer or other plan sponsor--as the educated "buyer" paying for these services--to specify the requirements and track the results.

"Employers need to audit their programs carefully to make sure the right information is available and that all the company's vendors are teaming up to serve employees who are experiencing an acute health episode," Emerick said.

In order to facilitate referrals, processes must be designed and put in place to help improve employees' health status.

"These types of benefits program are ripe for a Lean Six Sigma process" to map the current state of the process while identifying areas for improvement, added Emerick, who was heavily involved in a Lean Six Sigma initiative inside Wal-Mart.

To achieve their desired results, employers and other plan sponsors must work closely with vendors to ensure that the services provided are as cost-effective as possible while serving the health needs of employees. When multiple vendors are involved, this becomes quite the undertaking for the employer: measuring and tracking improvements in quality and cost effectiveness in areas such as utilization review, case management, disease management, nurse line, health coaching, EAP, health and wellness.

Optimal results can only be achieved with greater integration, cooperation and communication among vendors. While a vendor's relationship with an employer is essentially a business transaction, the common ground is the commitment to improve employee health and productivity while increasing satisfaction.

"No matter why a person is in one managed healthcare program, if he or she needs additional services, there must be a referral," Fairnot said. "For example, if someone is out on a workers' compensation injury as a result of a herniated disk and that individual also has diabetes or smokes, then he or she must receive additional services. Otherwise, the employer is going to end up spending more money on the case and the employee's heath and productivity will be impaired."

That wouldn't benefit anyone. Instead, case management and other healthcare management and wellness programs can work synergistically together to realize the desired financial, clinical and satisfaction outcomes of the plan sponsor and the employee.

MICHAEL GARRETT, MS, CCM, CVE, NCP, RMHC, is the chair of the Commission for Case Manager Certification, the first and largest nationally accredited organization that certifies case managers. He is also vice president of business development for Qualis Health in Seattle.

August 1, 2008

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