Patient Care Models

A prime example of how managed care companies are continually developing new models to better manage the total health care delivered to their membership can be seen in the new forms of patient care treatment. Standard utilization management programs are evolving into more proactive forms of health management.

Figure 1 depicts a framework for evaluating how three patient care models apply to members and their providers at various levels of illness. The general U.S. population has a wide variety of health needs based on differing demographics and health histories and, thus, people respond to different types of patient care. It is essential that a managed care company approach its broad membership base with a high level of sensitivity to these differences so that each member's healthcare needs are handled in the most appropriate manner, as opposed to forcing the entire membership case through a uniform and general set of UM protocols and methods.

Figure 1: Patient Care Model

 

Many industry experts believe that a patient care treatment focus will be a critical defining aspect of managed care in the 21st century. There will be a shifting emphasis from micromanaging episodes of care for an entire population to proactively managing each member's continuous health status, using the patient care model that most effectively addresses each member's specific needs. The models include the following:

• Health enhancement programs, which help assess the broad lifestyle of the individual member, provide broad-based education on proper self-care techniques, and provide more tailored, individualized counseling on preventive care, such as stress management, nutrition and weight control, smoking cessation, and safety instruction. Working with case managers, members can improve their personal health awareness, identify specific risk factors that may affect their future health care needs, and tailor specific behavioral change programs to help avoid potential health problems.
• Disease management is more appropriate for those members with identified chronic conditions (e.g., asthma, diabetes, heart disease, some types of mental illnesses) that require continuous monitoring and occasional, or regular, treatment. According to the American Medical Association, more than 105 million Americans suffer from one or more chronic disease, including those above, which accounts for a major share of the total national healthcare tab. Broader in scope than traditional UM programs, which primarily focus on managing specific episodes of care, disease management is a more systematic approach to health management, coordinating all levels of care, including prevention, control, and self-care to maximize cost savings and improve the quality of care delivered. It involves physicians as well as patients, and sometimes workplace medical personnel, in following clinical treatment guidelines, in educating patients on self-care, and in proactive intervention of chronic situations. Case managers monitor prior treatment history and current treatment regimes as well as ensuring that information is provided to physicians and patients. The Disease Management Association of America (www.dmaa.org/definition.html) lists six critical components for any full service DM program, including:
  1. Population identification processes.
  2. Evidence-based practice guidelines.
  3. Collaborative practice models to include physician and- support-service providers.
  4. Patient self-management education, which may include-primary prevention, behavioral modification programs and compliance/surveillance.
  5. Process and outcomes measurement, evaluation and- management.
  6. Routine reporting/feedback loop, which includes communication with both patient and physician.
  Disease management holds considerable potential in addressing the high costs associated with chronic healthcare conditions, however the evolution of these programs require national standards for measuring clinical performance as well as the willing participation of both patient and provider.
• Case management programs deal with specific, severe illnesses, in order to avoid unnecessary, inappropriate, or excessive care. Ideally, the member progresses through the prior stages of the patient care continuum to minimize the need for large case management, or at least start case management before the health problem has already reached the severe phase.

Increasingly, managed care companies are employing clinical specialists with expertise in areas of more common case management activity, such as AIDS, cancer, high-risk pregnancy and neonatology, head and spine injury, pediatrics, cardiovascular disease, and organ transplants. At this point, patient care shifts from primary care to highly specialized disciplines.

Carve-out arrangements, for benefits such as prescription drugs, mental health and substance abuse treatment, and certain medical/surgical expenses (e.g., lab, maternity) are becoming increasingly popular among larger plan sponsors that wish to apply case management on specific services. Some companies have developed highly specialized expertise in such areas. On the other hand, many diseases cannot be easily isolated into specific types of treatment and therefore must be treated more holistically. Cancer treatment, for example, often stretches across the spectrum of medical services—surgery, inpatient medicine, drugs, lab, and X-ray therapy—and treatments must be coordinated to ensure the best quality care of the patient in the most cost-effective manner possible.

As an important supplement to managed care plans, many plan sponsors are implementing wellness programs, designed to keep employees healthier over the long run and, thereby, reduce health care costs and increase productivity. Such programs also have the benefit of reducing turnover and absenteeism, which can have real savings for companies. Wellness programs are taking on more emphasis, particularly as the aging population encounters greater risks from chronic conditions which emerge from unhealthy lifestyles.

According to the Surgeon General and the Centers for Disease Control and Prevention (CDC), 61 percent of adults Americans are overweight or obese, which can directly increase risks associated with a wide range of health problems including heart disease, diabetes, stroke, cancer, respiratory ailments, arthritis and pyschological disorders. A recent study at Emory University blames obesity for 27 percent of the rise in healthcare spending between 1987 and 2001 with the proportion of obese Americans rising from 13.5 percent to 23.8 percent during that time period.

Combine those figures with the Surgeon General's estimate that less than one third of adults get the recommended daily amount of physicial exercise and over 40 percent are sedentary the risk for further explosion of healthcare costs because of poor lifestyle choices is obvious. Alternatively the potential for prevention is the focus of corporate wellness programs.

While many larger corporations have instituted various levels of wellness programs, ranging from in-house exercise facilities to discount programs at health clubs or weight-reduction programs, it has been difficult to quantify the actual long-term effectiveness of many initiatives since most programs are voluntary in nature and studies suffer from a selection bias in favor of those members who generally lead healthy lifestyles.

Achieving broad participation in wellness programs continues to be a significant challenge, especially among those members who suffer from poor lifestyles. Plan sponsors need to create supportive positions which provide employees with encouragement and rewards for healthier lifestyle choices. Plan sponsors need to avoid possible discrimination against employees who are overweight or may not excercise on a regular basis, even if the intent is to encourage them to lead healthier lives. In addition, healthcare privacy rules under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require employers to advise employees in advance about how they may use any personal health information and they must strictly maintain protection of such information.