Medical Case Management Best Practices

It’s no secret that today that health plans and managed care organizations are putting tremendous amounts of money into proactively managing the small percentage of their subscriber populations who consume the majority of their health care resources. Case management utilization review, medical management and disease management are some of the generic terms that are used to describe this process. Independent review organizations act as a key support element in the health care decision making process. They help case managers, utilization review and utilization management nurses improve the health care delivery process so that critical care populations are getting properly attended to with the right treatments, each time, every time. Only independent review organizations can provide for this critical decision support to the managed care organization. Managed care organizations, utilization review and utilization management departments attempt to perform these functions internally without using the appropriate specialists with the latest training in active practice run the risk of not being able to distinguish between necessary and unnecessary treatments. Such decision making is the role of an IRO.

Case managers outsource their medical claims decision making to independent review organizations for a simple reason: They don’t have the medical expertise and specialist knowledge in all areas of care management to make effective medical decisions concerning care recommendation for some patients. By involving an independent review organization in their decision making, case managers are able to allocate health care resources quickly and cost effectively to the right people with a high degree of confidence that those resources and those treatments were assigned effectively based upon the standard of care, medical necessity and what’s in the plan language. Case managers who use independent review organizations are able to improve their service to their clients and to their patients, assuring effective health care delivery. At the same time, IRO help streamline the decision making process and allow for treatments to happen earlier…sometimes with the added benefit of saving lives or improving patient outcomes. Case managers and utilization review managers who actively use IROs for this purpose often comment on how fast and easy it is to get quick determinations that improve medical outcomes for their active cases.

We’ve seen many examples of case managers using an IRO to speed up treatments and improve patient safety and reduce the cost over the patient care life cycle. Case managers and utilization review nurses who deploy IROs also find that it’s a much faster and easier way to make healthcare decisions compared to waiting on internal or allied doctors. Since independent review organizations are in the business of supporting fast and quality patient health care decisions, they’re able to make decisions faster, easier and at a lower cost compared to other processes. This is why case management, utilization review and other types of medical management firms are increasingly turning to IROs as a key resource in their healthcare decision making toolkit.

Doctor Alliance

The doctor alliance is a tricky one! On one hand, the each doctor takes a Hippocratic oath swearing to practice medicine ethically. On the other hand, you’d have to think about it logically. Suppose a doctor were faced with the notion of deciding whether prescribing medication would be just as ethical as coaching you on your diet? The medication would more than likely bring you back to health so wouldn’t it be ethical to prescribe the meds? In a recently written article: Doctors and Pharmaceutical companies, we discussed the fact that pharmaceutical reps offer doctors cash, trinkets as well as trips to tropical destinations in order for the doctors to prescribe their medications.

The Doctors and pharmaceutical companies (see bottom of this article for link) article exposed period in my own life when I was prescribed meds for high blood pressure Soon after, I was able to regulate my blood pressure by regulating my diet. I can’t say with absolute certainty that the doctor who gave me samples of blood pressure medication did it because they simply wanted to promote for a pharmaceutical company. In fact, I did need to do SOMETHING to bring my blood pressure back in line.

However, I do think that the doctors involved could have done more by the way of educating me and trying alternatives (such as diet changes) first. Pharmaceutical companies have been investigated as they some times walk a fine line between what is and is not ethical. Gene Cordoba (former rep) shares his experience in the industry. He states that he has heard reps boast of providing sports tickets to doctors, buying televisions for waiting rooms and even providing tickets to tropical destinations. Cordoba had much success in his days as a rep. His tactics included the simple lunches for the office.

However, if there were a doctor who refused to see Cordoba, he would target those around him. One unique tactic was sponsoring a little league baseball team or bowling league. Soon, the doctor would feel obligated to at least give Cordoba 10 minutes of time to share news of his drugs. Ten minutes is all that is needed when combined with the fact that Cordoba is shelling out money to help support the little league baseball team that the doctor’s son plays for!

There are plenty of examples of companies who are or have been under investigation for unethical tactics. Bottom line is that you are still dealing with individuals (doctors and reps). When there are individuals making decisions and money, lunches and vacations are offered, you will have individuals who will take those gifts and prescribe medication to you as a result.
What should you do?

1) Always ask questions. Don’t take any medications without asking why is this my only option.
2) Do your research. Google is a wonderful place that you can easily find more information about drugs, doctors, your condition and pharmaceutical companies.
3) Get a second opinion. You may be surprised at the difference in opinion.

Don’t be afraid to ask your doctor about his relationship with the detail men/pharmaceutical reps of the drugs he prescribes to you. When doctors know your line of thinking and that you are knowledgeable and paying attention to these things, he may be less likely to prescribe unless there is an absolute need, he feels that this is the best option for you AND he has no ulterior motives.