CMSA Today - Issue 3, 2016 - (Page 16)

Utilization Management Optimizing Workers' Compensation Programs through Integrated Utilization Management and Case Management Interventions BY GARRY CARNEAL, JD, AND CATIE SPIVEY, JD s case managers can attest, the services associated with "case management" (CM) and "utilization management" (UM) interventions are often intertwined and sometimes difficult to disentangle. This overlap is highlighted in many regulatory definitions that reference UM programs when defining the practice of case management.1 In addition, the CMSA Standards of Practice for Case Management highlights the overlapping role of CM and UM programs in "managed care" settings. Managed care is defined as: Services or strategies to improve access to care, quality of care, and the cost-effective use of health resources. Managed care services include but are not limited to, case management, utilization management, peer review, disease management, and population health.2 The emergence of "population health" management programs also has interwoven these services. In part, this is due to the fact that payers require that case managers not only coordinate care across the continuum of health care needs but also assess the medical "necessity and appropriateness" for a particular patient, set of patients, or specific disease diagnosis.3 If UM is considered the overarching process to control costs and access to care, case management can be viewed as one of the tools within that process. In other situations, 16 CMSA TODAY UM decision-making can be viewed as a sub-routine within the CM process. Statutory definitions often reflect the duality of this relationship.4 Clearly, UM and CM activities are often intrinsically linked. BACKGROUND Workers' compensation programs, as we know them today, evolved over a 30-year period. Over time, benefits were standardized, costcontainment and equity with state regulations were addressed, and return-to-work programs that benefit workers were introduced. Nurses assumed a central role in workers' compensation cases and were critically important to manage an ever-increasing number of claims.8 In 2011, state and federal workers' compensation laws covered approximately 125.8 million employees and paid out $60.2 billion in benefits.9 With payments under workers' compensation programs totaling $60.2 billion in 2011, which represents a 3.4% increase over 2010 payments, the need to contain costs via nurse case managers remains critically important.9 RETURN TO WORK (RTW) PROGRAMS The primary goal of UM and CM interventions within a workers' compensation setting is to help the ill or injured employee return to work as Issue 3 * 2016 * DIGITAL soon as possible. Nurse case managers are often deployed in return to work (RTW) programs where managed care services are offered and blended together to optimize clinical and financial outcomes. In one recent survey of employers using an RTW program, 66% reported that their workers' compensation claims either stayed the same or declined over a three-year period, and 64% reported that the amount of time of these claims also remained constant or declined.10 Employers with RTW programs found them to be an effective strategy both to reduce lost time and as a way to invest in their workforce.10 UM/CM INTERCONNECTIVITY As referenced above, the overlaps between UM and CM services is not always clear but is important to align reasonable and necessary treatment goals along with managing claim expenditures. It is not uncommon to see UM services embedded into telephonic and field case management programs, both for workers compensation and medical care settings. One key difference between UM and CM programs is in the duration of care that these interventions address. UM is typically an episodic transaction that involves a combination of management and clinical decision-making practices to ensure care is appropriate and medically necessary pursuant to the scope of coverage offered by an insurer, whereas CM

Table of Contents for the Digital Edition of CMSA Today - Issue 3, 2016

Tracking Outcomes and Return to Work Within the Hospitality Industry: The Marriott International, Inc. Approach
Optimizing Workers’ Compensation Programs through Integrated Utilization Management and Case Management Interventions
A Challenge for Case Managers: Engaging with the Multigenerational Workforce

CMSA Today - Issue 3, 2016