Healthcare Advocacy

Care Management today focuses on disease prevention and risk reduction through education, self-care and evidence based clinical programs in addition to timely and patient-centric care/health advocacy. The most effective care management is handled and directed via physicians. An informed patient increases the success of the management process. It’s not only important for patients to receive good clinical care and information it’s equally important that they receive “caring” and a good quality of life.

In the PIC model, the Case Manager is a combination of the patient’s Primary Treating Physician and Primary Care Physician with support from the Physician office staffs, other members of the care team, and PIC administrative staff. This model is benefit structure independent with the Primary Treating Physician situationally defined by the patient’s underlying condition and the Primary Care Physician defined as the Internist, Family Practitioner, or General Pediatrician who has followed the patient during both times of wellness and illness.

PIC partners with existing case management staff within Healthplans and Third Party Administrators to perform full case reviews and obtain information regarding recommended services. In a significant number of cases, existing case management staff encounter communication barriers with a very busy physician community and access barriers to patients and family. This has become increasingly prevalent where Case Management programs have been centralized on a regional basis and are reduced to telephonic interactions. Partners In Care staff have served as an effective conduit between case managers and the treating physicians, maximizing the intended effectiveness of these programs for patient benefit.

In some complex cases it has been recommended that patients and/or their families may benefit from the services of medical ethicists to assist in advanced care planning. CarePaths, a healthcare advisory service staffed by medical ethicists offer consultation on treatment decisions by or on behalf of patients close to the end of their lives. Like other consults, observations and recommendations of CarePaths consultants are advisory to those immediately responsible for direction of the patient’s care. This service may be requested by physicians, nurses, patients, family members or guardians of patients. The cost of the service is covered under some benefits. This service participates with PIC Administrative staff at the request of the treating physician, the primary care physician, the patient’s family, or the health plan’s case management staff.

To facilitate the identification of patients in need, PIC has positioned itself to be able to accept claims and membership data from varying sources and formats that is then:

Warehoused, Analyzed, and Reported upon
Key focus members are identified in 8 specific categories as outlined by the Institute of Medicine and the PIC Medical Directorate:
- Diabetes
- Asthma
- Circulatory
- Perinatal
- Neoplasm
- High cost
- High Provider Complexity
- Adverse events

Health Risk Assessments are used to identify members’ life situation and assists in highlighting life style risk factors that can lead to a member who may have the potential to become a complex case. PIC’s thinking is that early identification and intervention assists in reducing the costs to members and employers.

Various sources are used to retrieve clinical data on members (primary care physicians, treating physicians, case management personnel at Healthplans and Third Party Administrators). This information is then prepared into a proprietary report that allows an “at a glance” look at claims paid by incurred month, paid month, providers network classification, top 25 providers, top 5 diagnoses, top 5 CPT codes, top 5 medications, case notes, and claims detail.

PIC’s Medical Directorate reviews member related materials and recommends opportunities for referrals regarding disease management and medical management working in conjunction with Primary Care and Primary Treating physicians.

PIC’s Medical Directorate holds a monthly Complex Case Management Work Group Meeting which is staffed by members of the administrative team of PIC. Select Complex cases are reviewed to allow for group review and discussion regarding care coordination, appropriateness of care settings, unnecessary care, and multiple admissions, etc. The cases brought to this meeting are selected by the medical directorate and the administrative team during the case review process.

Disease Management Mailings are prepared and sent to primary care physicians and primary treating physicians. This process allows PIC to obtain current history as well as providing an opportunity to work with members who have not had a recent visit with their physician.

Care management integration can be maximized by focusing on the members (consumer) health and well-being, constant reinforcement of the importance of good health and care coordination, disease management programs via formal communication channels, and by showing a return on investment. Dollars saved through appropriate care are dollars that may be saved in the form of employee contributions.

The typical comprehensive health care advocacy process is tiered into three levels depending upon the risk adjustment of the patient. Typically the top .25% to .5% of the patient population will receive about 6-10 staff hours of centralized intervention. In some cases this can be doubled or tripled. In many cases, these same patients have been dismissed as not having a sufficient cost benefit by health plan case management departments, especially in self insured settings.

The second level makes up about 1.5% - 2.5% of the overall population. This level will typically utilize between 2-4 staff hours as the data needs remain intense but the coordination challenges are lessened from the previous tier.

The third level typically is 7.5% - 12.5% of the population. These patients typically demand very little in the way of staff intervention. The data collection and dissemination process is typically the scope of intervention. While volume is higher each patient demands about 1 staff hour per year. We typically receive very positive feedback from the treating physicians in that we are many times able to provide them with information that is not readily available to them.

This process can be structured and billed in a wide variety of manners.

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