June 15, 2005
An organized, systematic approach to case management can bring benefits for the revenue cycle as well as patient care. Combining clinical and financial records is a necessary, if challenging, step in developing an effective case management program because although case managers may have complete access to patients' medical records, they may not have equal access to the financial information they need to promote cost-effective outcomes.
A new educational supplement by HFMA and Cerner discusses the core components of successfully integrating these clinical and financial perspectives. "Clinical and financial case management can absolutely be combined," says Liz Alhand, former CFO, Presbyterian Healthcare Services, Albuquerque, N.M. "The formula for any change is always the same: people, technology, and process."
What Case Managers Don't Know About the Financial Side of Care
Case management nurses and doctors understand fairly well that inappropriate utilization increases costs. The payment rules, however, are less clear. "The training that experienced nurses need isn't on the cost side, it's on the payment side," points out Jeff Rooney, CFO, Rush North Shore Medical Center, Skokie, Ill.
"The payment rules are such that if we don't do things a certain way, we won't get paid. For example, if a patient is ready to be discharged after being treated for pneumonia on a care pathway, but the physician wants to order a big-ticket imaging exam for reasons other than the pneumonia, that's viewed as inappropriate utilization and poor quality because the diagnosis and other documentation don't support the need for that exam.
"The case manager also needs to know that Medicare pays the same flat amount for treating pneumonia, whether the hospital performs that exam or not. The case manager should advise the physician to discharge the patient and have the patient come back for the imaging study so the hospital will be paid for the service," he says.
Thus, case managers must be a part of a team of people who understand both the financial and clinical consequences of the healthcare decisions each member of the team makes.
"Insurance companies cannot manage care," says Brent James, MD, PhD, vice president for medical research and continuing medical education at Salt Lake City-based Intermountain Health Care and executive director of the IHC Institute for Healthcare Delivery Research. "They're too far removed from where care delivery occurs. The only people who can really manage care are those who are directly involved in it on a day-to-day basis -- physicians and nurses." IHC builds triads of people to provide case management of care, usually consisting of a physician who functions as medical director, a nurse who functions as a full-time clinical operations officer or case manager, and an administrator. Together the three set clinical improvement goals and discuss how best to manage care.
Key to Success
Successful case management, which integrates clinical and financial data and perspectives, requires concerted effort throughout the organization. The experts interviewed for HFMA's report agreed that keys to success include:
- The support and enthusiasm of top management
- Leadership from physicians and nurses trained to manage care with an eye to costs
- Electronic information systems capable of providing information on evidence-based clinical protocols and financial reports that help case managers promote high-quality care and save money on the cost of providing better care
- An ongoing process of gathering and analyzing clinical and financial outcome data
- The management skills necessary to use clinical and cost data to negotiate favorable reimbursement contracts
Case management is part of an overall process of improving the quality of care an organization provides, explains Alhand. "An organization needs the active engagement and passion of senior leaders in improving quality. That's probably the most important ingredient. Improving quality has to be a part of every conversation within the system and a part of every measure used to evaluate the success of the organization, both clinical and financial."
SOURCE:
The Case for Quality: Effective Clinical and Financial Case Management, a collaborative report by HFMA and Cerner.
Additional Resources
- Key Strategies for Sustained Performance Improvement
- ICD-10: Capturing the Complexities of Health Care
- HFMA Roundtable: The Road to Better Care: Merging Financial and Clinical Pathways
- Executive Roundtable: Improving Performance with Clinical Service Lines
- Executive Roundtable: Operationalizing Standards of Care: The CFO's Role in Clinical Pathways
- Cost Control: Comprehensive Listing of HFMA Products and Services
If you have questions or comments about HFMA Wants You to Know, contact editor Laura Noble.
HFMA Wants You to Know ISSN: 1540-0697. Volume IV, Issue 12. Copyright 2005, Healthcare Financial Management Association. All rights reserved.