The role of case managers in controlling hospital costs

Guest post by Kathleen Miodonski

Hospitals across the country are looking increasingly to their case management departments to provide support in this rapidly changing environment. Addressing rising healthcare costs is a key component of healthcare reform and has spawned a variety of new payment methodologies. Managed-care plans are tightening reimbursements and Medicare Recovery Audit Contractor audits are exerting even more pressure on hospitals' financial health.

Hospital case managers have been valued for their understanding of healthcare delivery and their ability to combine quality, efficiency and resource management in delivery of patient care. The need for an effective and responsive case management department has never been greater.

Here are five indications a case management department needs improvement:

1. Senior leadership is unable to identify the impact or describe the value of case management in their organization. Senior leadership may not understand what case management staff does, but the impact of case management activities should be evident and regularly reported. Case management impact on accounts receivable, length-of-stay and throughput data, denial rates for medical necessity, as well as appeals, overturned denials and use of observation status are some of the metrics that can demonstrate the value case management brings to an organization. Leaders of effective case management departments use tools such as a balanced scorecard to highlight the outcomes of effective processes and programs.

2. Physicians, particularly hospitalists, have negative or neutral attitudes and opinions of the value of case management. Physician practice patterns drive resource consumption in patient care. Successful case management departments understand this fundamental fact and have employed strategies to partner effectively with physicians. Collaborative partnerships with physicians promote cost-effective care through support of decision-making, promoting care progression and care coordination. Case managers add value to physician practice.

3. Key operational areas do not have a collaborative relationship with case management. Case management departments interact with virtually every department in the hospital. It is imperative, however, that the case management department has productive and collaborative relationships with the nursing, finance and contracting departments. The nursing department should recognize and support case management as a professional specialty. Effective care coordination requires case managers to work closely with the bedside nurses. Utilization review and denials management activities, coupled with open communication with the finance and contracting areas, can provide useful information about the effect of health plan contracts on operations and the revenue cycle.

4. The hospital's reputation with the payer community is not favorable for utilization management. Well-organized and executed utilization management activities in hospitals translate to smoother operations for health plans and an uninterrupted revenue cycle for hospitals. Case management departments that submit timely and accurate utilization reviews decrease denials from health plans.

5. Representatives of post-acute venues express frustration with discharge planning activities. Discharging patients to post-acute care is a complex process requiring skilled assessment, thorough communication with the healthcare team, patients and payers, and coordination of many ancillary services. Case management departments that can shepherd patients through this process smoothly will enjoy positive relationships with post-acute venues and patients alike. Consistently demonstrating well-executed discharge plans increases the likelihood that post-acute venues will partner with hospitals in accepting patients with more complex discharge planning needs--with positive impact on length-of-stay.

Editor's note: Kathleen Miodonski is a manager with The Camden Group in Chicago.