Studies Demonstrate Powerful Impact of Effective Case ManagementIn healthcare, fiscal responsibility and patient outcomes are essential to the bottom line, and both are significantly impacted by the efforts, expertise, and effectiveness of case managers.
Case management grew from a program in the 1970s designed to integrate social welfare services, and has since evolved into an integral part of providing quality healthcare. It has continued to evolve in the shift toward value-based care initiatives that tie payment to patient outcomes.
A recent study by Harvard Medical School researchers compared eight years of data from patients enrolled in Blue Cross Blue Shield’s Alternative Quality Contract (AQC) to a control group in other states. The AQC is a population-based payment model that includes rewards and penalties for healthcare provider performance.
The study found there was slower growth in spending and savings that, over time, exceeded the incentives. In the early years of the study, the savings were driven by lower prices, but as the program gained momentum, the savings resulted from a lower utilization of services, including labs, emergency room visits, and some imaging.
Value-Based Care and Improved Outcomes
Many of these results were the consequence of effective case management in vulnerable populations. Value is determined through improvement in patient wellness and a reduction in health insurance costs. Essentially, value is getting more and spending less.
This approach emphasizes proactive, preventive, and efficient care to achieve goals. Value-based strategies were implemented by insurance companies decades ago when they offered large businesses a reduction in premiums if their employees reduced the use of the healthcare system.
Employers began health and wellness programs designed to reduce smoking, improve weight maintenance, and change eating habits in an effort to reduce the burden of chronic disease. Improving outcomes has always been one of the top goals of case managers. Today healthcare systems are leaning heavily on this position, particularly in a changing environment.
Some hospitals are using case managers to schedule appointments for patients prior to discharge for follow up, while others are cutting readmission when case managers help patients with their medications and stay in touch after discharge. In this case, the hospital is saving $1,225 per patient.
Reducing Readmission and Extended Stays
The long-term benefit of coordinated, patient-centered care is a reduction in extended stays and readmissions. Hospitals are also experiencing a reduction in unnecessary emergency room visits and can eliminate unnecessary testing by using data to analyze and create a logical treatment sequence.
Value-based reimbursement relies on reducing readmissions as this indicates poor follow-up and management of chronic illnesses. In one case study, researchers instituted a pilot program of approximately 750 Medicare Advantage members and found 50% fewer hospital days for every 1,000 patients, 45% fewer admissions and 56% fewer readmissions as compared to an unmanaged Medicare population.
In this pilot program, the insurance companies and Medicare focused on care management to improve health outcomes and financial incentives.
Case Managers Are the Linchpin to Reducing Costs and Saving Healthcare
These are examples of how case managers can make a significant contribution to a healthcare organization’s bottom line, and why highly trained care managers are essential to optimum performance.
As many organizations continue the growth in value-based care, it will be incumbent on the case manager to identify the economic consequences in this changing environment and use their expertise and skills to enhance the process of raising the bottom line.
This is a unique opportunity to combine positive outcomes for patients and healthcare facilities, creating a win-win situation where the case manager is a requisite linchpin in the development of planning and executing care.
Song, Z., Ji, Y., Safron, D., Chernew, M., (July 18, 2019) Health Care Spending, Utilization, and Quality 8 Years into Global Payment. The New England Journal of Medicine. 381:252
Fink-Samnick, E., Owen, M., Rasmussen, T (March 20, 2013) 5 Ways Case Managers Contribute to a Hospital’s Bottom Line. Becker’s Hospital Review E-Weekly.
Claffey, T., Agostini, J., Collet, E., Reisman, L., Krakauer, R. (September 2012) Payer-Provider Collaboration in Accountable Care Reduced Use and Improved Quality in Maine Medicare Advantage Plan. Health Affairs. 31(9)
Bae, JM. (March 4, 2015). Value-Based Medicine: Concepts and Application. Epidemiology and Health. 37: e2015014