Health Care Reform Proposal Utilizing Case Management

Coordinated Care for All

Universal Health Care At 40% Less

Introduction of medical case management:

Medical case management involves the utilization of a Registered Nurse (RN), also known as a Nurse Case Manager (NCM), in the course of a medical claim. Most NCMs are also certified (such as with a CCM credential, which stands for Certified Case Manager). The NCM acts to facilitate communication among the involved parties of the claim (i.e., patient, provider and adjuster and sometimes the employer). They also coordinate complex aspects of medical care in order to achieve greater efficiency. The NCM prevents delays in treatment and also avoids miscommunication, which can often occur when an NCM is not used. NCMs also track a patient’s progress with regard to disease management. NCMs identify the most appropriate providers and resources, and they identify the most efficient pathways to recovery. With complex and catastrophic cases, in particular, NCMs coordinate complex medical care often too difficult for adjusters to manage on their own. In workers compensation claims, NCMs shorten the recovery process, allowing for a faster return to work and saving indemnity costs (benefits paid to an injured worker based on their loss work time). In the workers compensation sector, NCMs also assist with expediting the rate at which Maximum Medical Improvement (MMI) is attained, which is a major benchmark on the claim. NCMs have been utilized by the government for decades by the Department of Labor for government work-related claims.

Proposal of a new health care system:

Over the past couple of years I have worked to develop an alternative health care plan for the nation. This plan is multi-part in nature and combines various cost-saving components, translating the savings to manageable tax payment increases for the average household, and circulating additional savings (as with employer savings) back to the economy. The extra costs associated with the plan could also be additionally offset, at least in part, through re-allocation of existing budget funds.

Essentially, I am referring to a managed care organization of sorts (something like an HMO at the federal level). Cost-effective but quality medical care is the key. I believe that this plan would likely cost approximately 60% of government-administered health care without such savings implemented (as with Medicare, for example). The increase in tax payments will be less than the current health care premium payments per household. The cost savings realized by the average household could be circulated back into the economy (as with the consumer sector), thereby stimulating the economy. Another attractive consideration is that employers would no longer need to offer health care to their employees. If access to health care is provided by the government, there would no longer be the need for such an expense. Employers would also no longer need to pay for the health care portion of workers compensation premiums (though indemnity costs would remain). This would further help to stimulate the economy.

This new health care system is based on a Universal Health Care Model, sponsored by the government as a single payer source, but which allows for alternative private sector competition for those choosing to opt out (no mandate would be enforced). It is also based on the preservation of pre-existing conditions.

This new plan primarily focuses on prevention and incorporates health education to the public sector. It also utilizes medical case management and makes use of Utilization Review (UR) processes which adhere to standardized evidence-based guidelines. Other cost-saving measures include the development of pharmaceutical laws (in order to prevent out-of-control pharmaceutical costs) as well as the utilization of remote medicine (for lower-level, theory-based practice of medicine). The new plan also incorporates provider networks, which are based on pre-arranged contracts with reduced fee schedules. 

Central to the entire concept of this plan is medical case management. In particular, a centralized computer-based Case Management System (CMS) is pivotal in managing care properly and in monitoring higher risk cases, in an effort to focus on prevention. Tracking one’s health is essential to the concept of prevention (though patient privacy will also be adhered to). This CMS system would be automated for lower complexity cases (most individuals), providing unenforced education and recommendations for the prevention of escalated medical conditions. After a certain dollar amount is spent on a particular case, or a certain pre-determined complexity is reached, the system would then trigger active case management. Most active case management is telephonic in nature, and involves a specialized medical case managers (RN) coordinating care, facilitating communication, identifying the best resources and the most efficient pathways to care. A second-tier also involves field case management (RN community-based onsite case management) reserved for high acuity, complex and catastrophic cases. It should be noted that a large portion of health care costs involve the latter category. Extensive training (a six month roll out period) should be implemented specific to this type of specialized medical case management and for deployment of the CMS system.

I believe that a national set of guidelines should be developed by a panel of physicians and that standards for Utilization Review should also be developed. In addition, medical directors from various specialties should be utilized.

Another concept of the plan centers on the standardization of hospital/surgical billing. Often times there are a large disparity in costs for the same procedure between two different hospitals. I think this would help to the curb the climbing costs of health care.

Furthermore, the government could contract with areas of the private sector, such as with the Case Management System (CMS), which is already being implemented in the workers compensation sector, and which could be modified for the larger public sector.

Additionally, current Nurse Case Managers and hospital coordinators could be targeted for recruitment and training in deployment of the new system (an estimated 120,000 NCMs will be needed, though this figure still only accounts for 3.5% of the total RNs in the U.S.). However an even better idea, in my belief, would be recruitment straight out of nursing school, possibly even with a clinical round in school that focuses on case management. This would also eliminate the extra training costs being paid for by the government.

Also, there is value in the consolidation of medical records. Often, one provider doesn’t have access to another provider’s medical records. With the new plan, all medical records could uploaded/downloaded to the same computer database, accessible to all providers in the network. This could save a lot of money by preventing delays and avoiding miscommunication associated with limited access to care. Centralization of medical records would also prove valuable in the practice of remote medicine, when a provider requests onsite services for a patient.

Cost projections for the alternative health care plan: 

The annual cost of case management, along with cost associated with the centralized computer system (CMS), would only account for approximately 0.4% of the total cost of health care in the United States, including all additional labor (factoring in case managers as well as adjusters and admin personnel).  Medicare costs $700 Billion annually. Medicaid costs about $600 Billion annually. The Affordable Care Act (also known as Obamacare) is estimated to cost around $100 Billion annually. These government-sponsored health plans still only account for a portion of the population of the country. It seems obvious that a single payer source for health care could potentially replace Medicaid and Medicare, and would also incorporate the remaining portion of individuals in the United States. The estimated cost savings could be as great as 40%, or as much as $1.8 Trillion annually with the alternative health care plan.

Sources and Assumptions: Figures were taken from the NHE Fact Sheet at (accounting for $3.5 Trillion in total health care spending annually in the U.S.). Further assumptions include a workforce of 120,000 medical case managers nationwide, along with the associated support/administration personnel needed. The CMS system development and implementation costs are also factored in.

Arriving at a 40% overall cost savings:

I imagine that many people reading this may question such a large cost savings and that is understandable. However, I have been in the cost savings industry as a Nurse Case Manager for over 18 years, and experience informs my judgement. Most of the cost savings actually comes from prevention, which the CMS system (along with patient education) and utilization of NCMs are instrumental in accomplishing. Even if only 30% (a purposely conservative figure) of patients are actually compliant with the prevention focus, this would still account for a 30% reduction in preventable conditions. This, along with the 2nd most effective cost savings feature (efficiency) accounts for the majority of overall cost savings. Efficiency is primarily achieved utilizing the CMS system and NCMs as discussed previously (though consolidation of medical records helps as well). Other cost savings involve contracted rates, pharmaceutical laws, standardized billing, consolidation of medical records, and increased access to health care while decreasing provider costs (as with remote medicine). The UR process also eliminates unnecessary or inappropriate treatment, procedures or surgeries according to standardized guidelines. None of this even mentions employer-related savings, since the 40% pertains only to the relative costs of government-administered health care plans. Further cost savings analysis should be performed to account for the massive additional employer-related savings.

Implications for the Workers Compensation sector:

As previously stated, there would no longer be the need for premiums from employers based on the medical administration of a workers compensation claim. However, workers compensation carriers and employers would still benefit from utilizing Nurse Case Managers for the purpose of expediting the rate at which an injured worker returns to work, thereby reducing or eliminating indemnity costs (benefits paid to an injured worker based on their loss work time).

Paul Roberts RN, MS, CCM, CRRN