QUIZ 2: UTILIZATION MANAGEMENT: AN EVOLVING APPROACH TO MANAGING CARE

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Differ�nces!etween Case·Management apd Diseate Management �� ;Ii,'. i,t

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lra4fltioniVcatamophic case management Disease mal'lagement .!__,_ .• _'-------'.._ � --. -------'------"., • • , _u.....L.._ � :�.: .

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Empt,asts i's on $:iogfe patient, Ell'\phasis is on populatiqn with a chrohkJJlgess. _ � ·· ···.t•".·· · ... ,,,.,.,.," '' 1 •···· ·•")'"_•·· ltT·'·'"'• ·••·•,�-,., •. ).·'·' .. .. , .. ,r-�- ... .

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Earl;identfncatiQn of p��pre>wit� a�tite catastrophjc 'c:ondltion; . . . Fa�ly1dentificati�t), of ati p�ople ¥Jitp targeted �hroni� di�eases-(20�} {J(nown high cost or.known diagi,oses that lead to high cost in the whether mild; rnoderate,. or severe near term) :. � ' - 1lii --- ·--· ' ' • - __ ....,. ,,, • • '• ••• • ••-'• • -

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Acuity level of catastrophic cases rs high; aculty:'level oftraditi'onal ,,

Acuity level is moderate ca�es :is high to rno��rate· _ _ __ . _ . _. __ _

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- --·-

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• Ap�ftes t.o 0;5-:14!>_ of co�mercial �embe�hi'p . . �ppHes to 15-'.l:5% of�omn,er�f�I meQlbe�hlp_

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Value relies heavUy on price negotiadons and benefit flexing ·· ·

Value is result�f membef and p�qvrder beh�vior-change that results t� '"... ,. imptoved health status �

-. - •--:· ,. .. . ·- . �

--- _, -. . . -- --, - ... . . _,.. ... - _,,... - . .

Requir�s pl�n desfg� m�nipulation (�;g,1 adding ��re home care RequUes plan d,esign ch�oges that reward �nrollme�t:in DM and shrink visits) tfn,1� copay�

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Primary objective. is to ar.range. for care using the�leastJestrictive, Primary obJectrve i?to avoid hospitalization andmodlfy risk factors,. dinkally appropriate alternatives lifestyle, and-medication adhJrence to improve health statl,JS

,. • • • • • • • •' •' , ...,.: • • • • • "• • : ' .. • • •

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Episode is 60--90 days ..

Site of interaction primarlJy hospital, hospice, subaCute fadlify; or HHC

. - Drlven by need for arrangement of support services, community teso�ce�_

tr�nsportation Outcome metrics ijre single-admit LOS and cost per case

Note: HHC, home health care; LOS, length of stay.

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.. Intervention. is 365 days for '!'.�st conditions Site of interaction ·indudes wqrk�- school, t,orqe, and MD office � -·

Driven by non.adh�rence to medical regimens

. , . - '· -·.. - - .

Outcome metrics are annual cost per dfseased member and disease- .specific functional status and gap5. _in care

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