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Faced with rapidly escalating health care costs, employers are focusing on ways to save money by eliminating preventable expenditures. Often, this involves strategies such as educating employees about prevention and self-care. But it also involves better coordination of care when employees become ill or injured, and making sure that employees are following their treatment to reduce the likelihood of even more expensive treatments in hospital emergency rooms.

In other words, they are turning to disease management and case management.

This doesn't mean eliminating or reducing health care benefits. On the contrary, it means making better use of health-related services so that employees and their dependents get the care they need when they need it, as well as receiving education and support to promote wellness.

Disease management and case management belong to a multitiered approach to care and wellness in the workplace.

The first level is population health, which takes a "big picture approach" by looking at the needs of the entire employee group (e.g., blood pressure screening for employees).The next level is disease management, which targets groups of employees who have been diagnosed with or who run a high risk of having specific diseases or health issues, such as diabetes or heart disease.

Another level is case management, which advocates on behalf of an individual employee who needs coordination of care, usually as a result of a specific event, such as the onset of illness, an accident, or a flare-up in an existing medical condition that is compounded by other health issues.

Disease management and case management cannot be rolled out in the same way at every employer. Rather, it takes a customized strategy based on the specific employee population in order to get the most out of these two approaches.

For employers looking at health care from "the CFO perspective, they are trying to manage the increase in health care spending year-over-year," said Rufus Howe, vice president of product development for Nashville, Tenn.-based American Healthways Inc., a provider of specialized, comprehensive disease management, care enhancement and high-risk health management services. "Now, they recognize that money is the end point. The process of getting there is care management."

Increasingly, employers have come to expect that their health plans and other vendors provide a care management solution that encompasses both disease management and case management. To get the most out of both, these programs must be coordinated and precisely timed, with communication and cooperation among all the players involved.

They may include the company's liaison with the health plans (whether internal or an outside consultant), the insurers, disease managers and case managers, physicians and other care providers.

Most importantly perhaps, just as medicine is most effective for a patient in the correct amount, so too the health care strategies implemented in the workplace must be just the right "dosage." Not every employee will require disease management, nor will every health care intervention require case management. The key is the right amount of intervention and service at the right time and with the right frequency.

"Employers need to tailor their health care programs to their specific company and their specific population," said Kathleen Ward Douglas, president of K.A. Shannon Consulting LLC, in Phoenix, Ariz., which provides medical management solutions for large employers through strategic program design.

"Employers need to understand that they are in the driver's seat; they are the ones paying the health care coverage bill. They need to demand and expect the programs that work best for their population."

Health plans, too, recognize the value of case management and disease management as part of their strategies to offer comprehensive and integrated services to employers.

"If I am a health plan selling to an employer, I'm telling them how the health plan pays claims and manages costs by doing this and that," Howe said. "But that is all 'mind stuff.' There is also an important 'heart' component. Yes, we do a lot of transactions, but employers are also paying for care for the members, and to ensure that the care is of the highest quality possible. Part of this, we believe, is something called disease management and part of it is something called case management."

For the employees, who are the ultimate consumers, the distinctions between disease management and case management should not matter at all.In fact, the better integrated the programs are the more the employee will experience them as part of one, seamless service.

"Employers are saying, we want one point of contact with 24-hour-a-day, 7-day-a-week service. Call that person the advocate or the navigator or the care manager; it doesn't matter.Just don't fragment the services for my employee population any more," said Douglas.

Although employees may experience these services as seamless, behind-the-scenes disease managers and case managers fulfill specific roles. With better communication and coordination--including using a plan or "map" that shows how, when and to whom calls from employees are routed and referred--disease managers and case managers complement each other.

"The root reason for disease management really is to provide education and support services for people who are at risk," Howe said. "Let's say an individual has heart failure. From the day of diagnosis, statistically speaking, that person is probably not going to live more than five years. Along the way, however, there are things that can be done to improve the quality of that person's life day to day, and to avoid unnecessary emergency department visits and hospitalizations."

Through disease management services, the individual is educated about self-care, from the importance of following the treatment regimen to eating a healthier diet. That individual, however, then suffers a health event: for example, a stroke. At this point, the immediate need is care coordination. This is when the case manager steps in.

"When an individual is very sick and needs home health services, specialists, particular medications, rehabilitation--this is an event-driven situation. What's needed is marshaling resources. From a case management perspective, this means trying to reduce cost elasticity," Howe added.

The cost elasticity reflects the fact that the patient, whose cost to the health plan may have been, say, $400 a month, has now shot up to $4,000, $5,000, or even $20,000 a month because of a critical health issue.

With case management, however, treatment and other care services can be managed for the best possible use of resources and an optimal patient outcome. When the patient is stabilized again and the cost per month is reduced, the individual may return to the disease management program.

By coordinating disease management and case management, emphasis is placed on the whole patient?not just the disease or condition that arises. This approach also acknowledges that individuals may have more than one health issue or chronic condition.For example, an employee suffers a heart attack and is hospitalized.

A case manager is assigned to coordinate care and act as an advocate on his or her behalf in the health care system. That same employee, however, may have other underlying conditions, such as hypertension or diabetes. Through disease management, the patient can be educated about self-care and steps to promote wellness.

Another consideration in the disease and case management scenario is depression, which is a common co-morbidity among patients. According to industry statistics, depression affects 40 percent to 65 percent of cardiac patients, up to 27 percent of stroke patients, 25 percent of cancer patients, and 25 percent of patients with diabetes--a condition that is one of the most prevalent in the workplace.

With better data management, information can be shared, as appropriate, between case managers and disease managers. Operating under the umbrella of the health plan, they are privy to information that must be kept confidential from the employer.

This access to data, however, is vital not only to manage individual cases, but also to predict the need for future interventions and wellness initiatives. If, for example, health claims and pharmacy claims data shows a rise in diabetes, disease management programs targeting detection, care and prevention can be introduced in the workplace.

This is also part of the "dosage" approach to disease management and case management, ensuring that individuals and specific employee populations receive relevant and custom-tailored services--instead of blanket approaches that are not as targeted and therefore either not as effective or wasteful.

Employers not experiencing this level of integration among their case management and disease management services--which could involve several different vendors working with their health plans--can demand more from their providers, said Douglas.

"Employers should expect all their vendors to collaborate with each other, and they should expect workflows that demonstrate how they all intersect, so that there is a line in the sand among the providers. There must be a clear line of demarcation among providers about who is handling what, otherwise the person will again be lost in this process."

As companies focus on their expenditures for health plans, the need for better monitoring, coordination and strategic planning is apparent. The desired end may be fewer dollars spent on health care through better utilization. The path to achieving that goal, however, is focusing on employees and their specific needs. For companies that take this approach, using disease management and case management strategies, the result could be healthier, more satisfied employee populations who receive the care that is needed, at the right time, and in the right dose.

DIANE HUBER is the immediate past chairwoman of the Commission for Case Manager Certification, which certifies case managers. She is also a professor at the University of Iowa College of Nursing.

MINDY OWEN is chairwoman of Commission for Case Manager Certification (CCMC). She is also principal of Phoenix Health Care Assoc. LLC, a consulting firm specializing in case management, disease management, and managed care development and education.

January 1, 2005

Copyright 2005© LRP Publications