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Hospital Case Managers Man Front Lines of Cost Containment
Story Number is : 052612100
By Thomas Rasmussen
Hospital Newspaper

Case managers in hospitals are playing a vital role in the health care system today as they serve not only as advocates for improved patient care but also as they work to ensure that health plans cover the cost of care.

In this role, case managers are serving what might at first seem like a conflicting function: ensuring that patients get the best care while containing costs. Working in this capacity as patient advocate and cost-containment specialist, case managers are taking on a larger role in the health system than they have at any time in the past, according to Mindy Owen, RN, CRRN, CCM, a case manager and principal with Phoenix HealthCare Associates, LLC, in Coral Springs, Fla. Phoenix HealthCare Associates develops and implements case management programs for hospitals, health systems, and health plans nationwide.

A registered nurse with more than 30 years of experience in health care, Owen says the role case managers’ play today is vitally important because too often health plans and hospitals follow conflicting patient care criteria and guidelines. Without effective case management, patients might not get the most appropriate care or could easily get stuck with bills for unnecessary care and interventions, she said.

In most hospitals, there is not enough communication between those who provide care and those who pay for care, added Owen.

“Managed care organizations tend to work in their own silos and expect that all patients will be cared for according to the guidelines (Milliman) health plans follow,” Owen explains. “But for a variety of reasons, providers – meaning hospitals, physicians, and hospital staff – follow a different set of criteria and guidelines (InterQual) for care that are not the same guidelines health plans follow.” (Read further for a brief explanation of the Milliman and InterQual guidelines.)

No Communication

Another problem case managers face is that hospitals and health plans often do not communicate with each other, Owen explained. “When that happens, we are not serving our patients or our hospital customers well because it means we are just staying in our silos,” Owen commented.

“When we are not communicating and not collaborating, we are not delivering the kind of care I would want for myself or for anyone in my family.

“The result is providers and payers end up often having adversarial relationships,
and that can be incredibly frustrating for everyone. Plus, it results in poor patient care,” she added.

“Obviously, delivering anything less than the best care is just unacceptable.” For this reason, Owen recommended what she calls integrated case management. Such an approach involves having case managers for both hospitals and health plans work together and communicate about the best ways to deliver care for each patient.

“Integrated case management would help us to have better patient outcomes and lower costs because all case managers would be working from the same tool kit,” she said. “You could also provide a much more successful patient experience, and all of these factors are critical to payment today.”

Finding Help
To help case managers avoid conflicts in care management, Owen recommended that they take the contemporary courses on Athena®. That way they can learn what’s best for patient care and for their hospital employers as well.

When case managers take courses from Athena Forum, they are much better equipped to navigate the various and sometimes conflicting guidelines that hospitals and health plans follow, she explained.

Also, busy case managers can use the Athena Forum online courses to maintain their licensure and certifications at any time, day or night, and on weekends and holidays.

“Case managers are nurses and social workers who need to maintain their licenses, and on Athena Forum they can learn how to improve the performance of the hospital while simultaneously staying current with their license” she said. “In this day and age, it is difficult to get continuing education on the job because you are running so fast from one problem to the next all day. You don’t have time in an eight-hour shift at the hospital for anything but managing the individuals and families you serve.

“That’s why Athena Forum courses are ideal,” Owen said. “They allow you to have 24/7 access to current and updated educational options anywhere and at anytime.” Many hospitals with CM teams enrolled on Athena Forum report new ways to reduce costs including: Reducing avoidable delays, improving claims, and cutting readmission risks while improving staff satisfaction and job performance.

Guidelines Used More than 1,000 hospitals use Milliman Care Guidelines, which are evidence-based clinical guidelines and software that hospitals and other providers use to help ensure that patients get quality care, according to Milliman Care Guidelines, LLC, in Seattle, a division of Milliman Inc., actuaries and consultants in New York.

Hospitals use the Milliman Care Guidelines to identify and reduce variance from best practice, and to document appropriate evidence-based levels of care to improve care quality and efficiency, according to Milliman. Here’s the website for Milliman’s Care Guidelines: Http://

The InterQual guidelines are among the care management products offered by McKesson Inc., in San Francisco. McKesson says its case management guidelines help providers improve overall coordination of a health plan member or patient’s treatment plan to ensure optimal care. Case managers can use the guidelines to coordinate multiple treatment plans to reduce fragmented care, to refer members to appropriate local and community services such as behavioral health programs and home health agencies, and to and to manage patients along critical pathways to achieve the desired outcome
in a timely manner, McKesson says. Here’s the Web site for McKesson’s care management products: 2BPayers/Private%2BSector/Care%2BManagement/Care%2BManagement.html.

Thomas Rasmussen is the publisher of Athena Forum. He can be reached at For more information about the Athena Forum, visit
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