As defined by the Case Management Society of America, the textbook definition of medical case management is:

“Case management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes.”

However, because medical case management is almost always an ancillary service, subordinate to the statute/policy driven claim management process, the role of medical case management is often defined by the entity that employs it. Medical case management has generally been regarded as a service utilized to accomplish certain goals in the management of a claim (workers’ compensation, disability, liability, group health, etc.) and represents an added cost to the overall cost of that claim. Some reasons medical case management might typically be employed include:

Serious and/or complicated medical issues that require close coordination

• Uncertain or conflicting diagnoses
• Ambiguous, questionable, or varied treatment plans
• Medical issues and associated disabilities are not resolving timely
• Unfamiliar with providers

Generally speaking, when a claims professional feels that a claim is getting out of control or is approaching a juncture that requires special attention to keep it on course they consider employing a medical case manager. In addition, the value of the case management intervention is usually assessed in context with the specific goals the claims professional had in mind at the time of their referral. Accordingly, medical case management becomes just another tool in the claim professional’s toolbox. In this context, the value of medical case management is highly subjective. In this context, the cost of medical case management may, at times, be difficult to justify.

For the reasons noted above, we often see companies attempt to contain the cost of medical case management services by limiting case management activity to specific tasks or by limiting the scope of the case manager’s involvement in the treatment, rehabilitation, and/or return-to-work process. This cost based approach to utilizing medical case management only sees the service as a costs factor, ignoring or discounting the significant savings effective medical case management can deliver.

To evaluate the real potential value of medical case management services, one only needs to look at the area of workers’ compensation. Over the course of two decades, Gallup, Inc. and then the National Council on Compensation Insurance (NCCI) looked at the cost of treating and resolving work related injuries versus similar non-work related injuries. Both organizations found that work related injuries will have an average cost that is about 70% than the same injury treated through an individual’s group health insurance. The main reason for this phenomenon has been linked to the fact that work related injury claims will be open about 4 times longer than similar non-work related injuries. Because the claims are open that much longer, utilization of medical services more than double. Compounding this apparent overuse of medical services is the fact that, even with a plethora of discounted medical services, supplies, and diagnostics, the cost of medical services experiences an inflation rate at least twice the CPI, often reaching double digit increases.

How does this affect workers’ compensation claim costs? In all but 2 of the last 18 years, claim frequency has decreased. But while fewer workers are experiencing work injuries, the overall cost of work related injuries continues to increase. This can be attributed to the fact that medical costs continue to escalate at nearly double the pace of indemnity compensation for lost work time. If medical costs are the driving force behind the growing cost of claims, doesn’t it make sense that effective medical case management can make a difference in controlling claim costs?

While medical costs seem to be the driving force behind escalating workers’ compensation costs, this does not mean that we should not look at ways to reduce an injured worker’s time away from the workplace. In any given year between 3% and 5% of an employer’s workforce will experience a work injury. According to Department of Labor statistics, 30% of those injured workers will miss at least 2 days of work. When a worker misses work due to a work injury, the employer (or their insurer) must, by law, bear the direct cost of medical treatment, wage replacement, and any settlement costs due to permanent impairment. In addition, OSHA has noted that indirect costs ( lost production, temporary employees, training/retraining, etc) associated with missed work days is approximately 4.5 times the direct costs. When you consider that the average cost of a lost-time work injury is estimated by the Workers Compensation Research Institute to be ~$ 27,000, the real cost of the claim for the employer could easily approach $ 150,000.

In addition to being costly, time away from work can be detrimental to an optimal and timely medical recovery. Valid reasons for an injured worker to not report to work include:

• The worker must attend a medical evaluation or undergo treatment at a provider facility
• Injury is severe enough to require confinement at home or in bed
  • Acute nature of injury requires “bedrest”
  • Work related illness is contagious and would put other workers at risk
  • Injury requires protected environment to prevent contamination or exacerbation of injury/illness
• Work activity of any kind or commute to workplace has the likely potential to aggravate the work injury or lengthen that stage of recovery/rehabilitation

A survey of over 3000 occupational health physicians asked, “How often is disability medically required?” 90% of the physicians surveyed said less than 10% of the work injuries they see would require more than 2 lost work days for purely medical reasons. The fact is, most lost work days arecaused by discretionary or unnecessary factors such as:

• The employer’s perception is that the injured worker could possibly do something useful but…
  • “There’s no way to get the injured worker to/from the workplace”
  • “There is nothing the injured worker can do to make any substantial contribution”
  • “The support required to allow the injured worker to return to work is more than makes good fiscal sense”
  • “There are no jobs the injured worker can do that are within their medical restrictions
  • “Existing company policy and/or labor contract prohibits returning injured worker to light duty”
• Non-medical psych-social issues affecting the injured worker’s recovery are not addressed because they have not been identified and may be masquerading as additional medical issues.
• For whatever reason, medical treatment has been inadequate or inappropriately delayed
• Time lost from work attributed to medical issues but is really due to:
  • Poor communications/information flow
  • Lack of cooperation of any stakeholder due to the decision maker’s lack of understanding of dynamics of the injury/treatment/return-to-work process
  • Bureaucratic issues creating administrative/procedural delays
  • Disjointed management structure, leading to poor accountability and shifting of responsibilities on important decisions

Effective medical case management can proactively address and diminish the discretionary and unnecessary factors that hinder an injured worker’s attempts to have a successful return-to-work.

As you can see, in workers compensation, costs associated with both medical treatment/rehabilitation and lost work days can be optimized by attacking the barriers that delay progress in the treatment, rehabilitation, and return-to-work processes.

The medical case manager is uniquely positioned to evaluate, coordinate, and facilitate the injured worker’s progress in this endeavor. Injury management in any scenario is time sensitive. Delays and/or diversions in the diagnosis, treatment, and recovery process can result in less than optimal outcomes and increased costs. Injury management in the world of workers’ compensation is time critical!

This world is prone to delays and diversions in the diagnosis, treatment, and recovery process. Without proper intervention, work injuries are likely to result in less than optimal medical and vocational outcomes and costs that almost double the cost of treatment for similar non-work related injuries. Medical case management, when properly implemented, will generate results and associated savings that more than offset the cost of the case management services.

Medical case management is most effective when it is allowed to develop and implement a comprehensive case management plan that considers all aspects and all stakeholders in the treatment, rehabilitation, and return-to-work process.

An effective medical case management program should have goals that include:

• Assuring an accurate and thorough diagnosis of injury
• Coordination of the total span of an injured worker’s medical treatment
• Assuring a timely compliance with all medical treatment to facilitate an optimal functional outcome
• Avoiding unnecessary/unproven medical care
• Assuring appropriate utilization of resources (concurrent utilization review)
• Attaining medical stability/maximum medical improvement (MMI)
• Facilitating an early return-to-work (RTW)
• Avoiding complications and/or re-injury
• Achieving a reduction in the overall cost of the claim

These goals will be accomplished when the medical case manager focuses on:

• Educating the disabled worker about their injury and the rehabilitation/RTW process
• Guiding the disabled worker to the most appropriate provider for their injury
• Educating the employer about their disabled worker’s injury and the rehabilitation/RTW process that lies before them
• Educating the provider(s) about the functional demands of the disabled worker’s pre-injury job and any transitional work activities available, facilitating the earliest possible safe RTW
• Motivating the disabled worker in their compliance and completion of the rehabilitation/RTW process
• Keeping everyone involved in the disabled worker’s rehabilitation/RTW process fully informed at all times regarding progress, developments, and setbacks

To accomplish these important components of the medical case management process, it is vital that there is accountability. The company employing the medical case manager should have some way to evaluate case management outcomes and value, but should not be responsible for managing the way the case manager performs the various aspects of their job. The key to consistently realizing effective case management results is to employ a medical case management company that employs best practices, quality assurance, and ongoing supervision and coaching on the files assigned to their case management team.

Effective medical case management will transform routine case management activity from a task oriented service that adds cost to a claim toward a process integral to the successful, cost effective resolution of the claim. Effective medical case management is truly an investment that will generate a real return in the form of better medical and vocational outcomes, avoidance of unnecessary utilization of services, and overall lower claim costs.

Effective medical case management will motivate the injured worker to take full advantage of their medical treatment and rehabilitation programs. This will generally result in better functional outcomes, less lost work days, reduced pain and suffering, and a faster return to “life as normal.”

Effective medical case management will assist the employer in finding meaningful transitional work opportunities for the injured worker. This will mitigate production deficits experienced when a worker is not able to return to their normal job duties. Meaningful transitional work will be therapeutic, therefore, hastening the recovery process and diminishing the time the injured worker will be away from their normal job duties.

Effective medical case management will drive the medical treatment process forward at a pace appropriate to the recovery process. Providers will be reassured that the injured worker is receiving appropriate supervision and follow-up in their attempts to achieve rehabilitation goals and early reentry into the workplace.

Effective medical case management will assist the claims professional in closing files more quickly. By facilitating expeditious progress through the medical system, better functional outcomes, and safe/early returns to work, costs associated with medical treatment, lost workdays, and impairment permanency settlement will all see significant reductions.

The simple question – “What is case management?” – does not seem so simple when we examine how it is typically utilized versus all the potential benefits an effective case management program can deliver. Understanding what the medical case management process can really accomplish provides a better understanding of ways to really lower claim costs while optimizing service to the employer and the injured worker. With all this in mind, I would say we need to define “effective” case management, and I would offer that definition as follows:

“Effective medical case management is a results oriented, collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s medical andvocational needs through effective communication and coordination of available resources to promoteoptimal, cost-effective outcomes.”

About the Author

Vernon Poland is co-owner and General Partner of PDM, a full service medical case management company providing case management services throughout the Midwest. Vernon has worked in disability management industry for 15 years, developing and implementing programs and services to minimize lost work days while facilitating optimal medical and vocational outcomes. Prior to joining PDM, Vernon worked as a consulting engineer in the chemical industry for 17 years, working in varied industrial environments while consulting with clients on chemical applications and associated safe work practices.