Determining if an insurer case manager is right for your practice

When Ellen Brull, MD, was asked in 2011 by Advocate Physician Partners, part of the Illinois-based Advocate Health Care System, to allow a manager to coordinate care for patients from her two-physician family medicine practice in Niles, Ill., she thought it was a good idea. The arrangement still is running smoothly, although she understands why some doctors might be skeptical.The case manager "is doing things that I could do, but I don't have the time," said Dr. Brull, who owns her practice with another physician. The practice is a member of Advocate Physician Partners. "I know some physicians are leery, but [managers are] not there to modify what you're doing."
Insurers and health systems increasingly are offering case managers to work at independent practices as a way to reduce expenses within accountable care organizations or patient-centered medical homes. Experts say physicians need to do more than react to long-standing mistrust or consider if an empty desk is available.
There are key issues to contemplate before accepting a case manager, also called a care manager or nurse health educator. A good fit can improve patient care and help earn the practice various bonuses. A bad fit can be a waste of time, space and effort.
"It's a matter of finding out the particulars to determine if it will work or not," said Teresa Treiger, RN, principal at Ascent Care Management in Holbrook, Mass., which advises health care systems and medical practices looking to implement case management programs. "Taking advantage of these resources is not a bad thing, but it needs to be right for the practice. Is it worth it for a case manager to take up office space?"

Keeping case managers busy

Case management experts say the first question to consider is whether the practice has enough eligible patients to keep a case manager occupied. Those employed by an insurer usually are restricted to working with patients on that company's plans. A health system may want to focus case management efforts on patients with certain medical conditions to lower care costs and qualify for shared savings bonuses from Medicare or commercial insurers. Patients have the option of declining to participate.That does not mean the practice has to be large or have enough patients to keep a case manager occupied full time. Some insurers and health systems split case managers between several smaller practices. For example, Dr. Brull shares hers with another physician group.
If the practice has a suitable patient volume, the next consideration will be to ask what the case manager will do and how that fits with the practice's vision, mission and values. Several studies have shown that case managers can improve patient care, but the expectation by those funding these programs is that they will reduce costs. How will that be done, and does that suit the practice? Is the physician comfortable with the tasks assigned that the case manager will handle?
Duties can vary widely but should be spelled out in any contract covering the arrangement. Those tasks may include helping patients with transportation needs, motivating them to improve diet and physical activity, and managing transitions from the inpatient to the primary care setting.
The case manager, who typically is a registered nurse, also may help patients navigate specialty care and access preventive services. Some managers sit in on the doctor visit. Others talk to the patient immediately after the appointment.
Whatever the setup, it has to be a comfortable fit for the physician and others at the practice.
"The larger goal of any insurance company or health system is to reduce the cost of care," said Lisa Bielamowicz, MD, senior vice president of physician strategy at the Advisory Board Company, a research and consulting firm in Washington. "But how is a case manager going to improve the health of your patient?"

Who's in charge?

Another key question is how much control the practice has over a case manager's work. Although embedded case managers are not employed by the practice, that does not mean they have free reign. A practice should have input into their work. It should have the option to interview the individual much like a potential employee and stop working with him or her as appropriate. Such issues should be spelled out in the contract."It almost needs to be handled as if you were actually hiring them," said Cheri Lattimer, RN, executive director of the Case Management Society of America. "You need to look at the personality and experience of the individual who will be working with patients at your practice."If a practice turns down an offer of a case manager from an outside entity, an insurer or health system may provide money for the practice to hire one. That type of arrangement may have fewer restrictions, but it leaves practices with the challenge of hiring and directly managing the person. u{L}Elliott{/L} covers practice management issues. She can be reached at 312-464-5577 or by email {i}([email protected]){/i}.Webref||2012/07/23/bisa0723.htm||
Webref||2012/05/28/bise0530.htm||
Webref||2012/05/14/gvsa0514.htm||
Webref||2012/04/30/prsa0430.htm||
Webref||2012/03/05/gvsa0305.htm||
Webref||2011/10/03/prsa1003.htm||
Webref||2009/07/06/gvsa0706.htm||
Webref||2004/09/13/bisd0913.htm||
Twitter:
.@IllinoisAFP (Dr. Brull)
.@advocatehealth
.@TheAdvisoryBd
.@Cheri_Lattimer