“Defining Outcomes from Case Management
Cost Benefit Analysis Reports:

It’s my pleasure today to introduce our final speaker, Catherine Mullahy, president of Options Unlimited, a medical case management and benefits consulting firm in New York. Catherine is a nationally-recognized case management consultant and spokesperson for the case management industry. She is the recipient of the 1999 National Award of Distinguished Case Manager of the Year, presented by CMSA. She is president-elect for CMSA, so we’ll be seeing a lot more of her next year, as well chair of the Commission for Case Manager Certification, and serves on ongoing, expert panels in connection with the development of CCM credentials. So now you guys all have an in. Among other committees involvement, she is editor of the Case Manager magazine. Her book, The Case Manager Handbook, is often referred as the case managers’ bible and was named Book of the Year, in 1998, by the American Journal of Nursing Magazine. We have asked Catherine to share her knowledge and wisdom, regarding defining outcomes via cost benefit analysis reporting. Please join me in welcoming Catherine Mullahy.

What I hope to accomplish today is to kind of complete the circle that David Nash started out with. It seems like several days ago. It was several days ago, but when David talked to us during his keynote presentation, he mentioned to us how everything in healthcare today needs to be accountable. We all need to be accountable.

We are looking for healthcare providers for pharmaceutical companies for all the advanced technologies that we have today. We look for them to be accountable to us as consumers and payers of healthcare.

Case managers have a very integral part in all of that. So that we are all on the same side of the page and because some of you I know from the case management world and others of you I do not know so well, I would like to start out at least with a couple of basic definitions. So we make sure we understand when we are talking about the cost benefit and outcomes from case management, that we know and we are in agreement on what case management is and what it is not.

So case management as defined by The Commission for Case Manger Certification, by CMSA, “it is a collaborative process which evaluates and monitors and implements and accesses and changes, as patients’ needs change to promote cost-effective outcomes, quality outcomes, to deliver the right care to the right person, at the right time, in the most-appropriate setting, in the most cost-effective manner.

So, when part of our practice standards and part of the very definition addresses cost and addresses cost-containment, surely then some of our outcomes that we define need to address that as well. So I’m going to spend some time with you this morning in creating an environment that, perhaps, makes it a little bit more comfortable for us to talk about that as an outcome.

And I want to stress and underscore that cost should never drive what it is that we are doing as healthcare professionals and those of us that are involved in the payer community. We should never solely be looking at cost and make that our modus operandi. But surely, we need to realize and recognize that case management is an overhead in the healthcare delivery system.

We are in their positions, you as payers and maybe overseers of case management programs, we all recognize that we become an additional burden in the healthcare delivery system.

The kind of reports that I am going to talk to you about this morning, I believe form the basis of a quality assurance program for your payer organization, for your claims administration organizations, through your case management managed care departments.

When I am talking about case management, I am not talking about some of the elements of case management that make up the broad spectrum of it. I am talking about case management as David was talking, and I think we all realized today, when we manage the cases, the big complex cases that we all know about, these folks don’t just have one disease, one problem. They are not just a diabetic; they are not just a COPD patient; they are not just a chronic renal failure patient. These people have many problems, many illnesses, social conditions, cultural barriers, financial issues, work issues, family issues that make them the dilemmas and challenges that come to us in case management.

So we need to recognize then that, if we are to truly be successful in our case management departments and programs, we need to be able to define what it is we do. What do we bring to the table? Why are we there?

Case management, as you know, is all across the whole healthcare delivery system -- on the payer side, on the provider side, in employer groups, in the public sector, and in the private sector. It is all over the place. And it’s there because everyone recognizes that there are these complex problems; and, certainly also, everyone recognizes that we need to be more effective in getting people the access to the services that they are entitled to and that frequently these kinds of folks are falling through -- not just little cracks in the system. They are falling through abysses in the system and case managers help to address those needs.

To recognize how we have to define these costs, and today’s presentation, I don’t know whether it struck you as it struck me, but in Karl’s presentation and the doctors’ presentation, it is the first time in a very long time that I actually saw dollars and cents presented. Where have these figures been? And so a little bit of discussion on this aspect is, I think, really important and will help us be more comfortable in approaching what we need to be able to do, in terms of case management is to define in a language that everyone understands what it is that we do.

Now for those of you in the audience that are healthcare professionals, we are very comfortable talking in the medical jargon and a lot of the medical jargon that we have been listening to in the past couple of days, but the people who want to know what it is that we bring to the table are not necessarily comfortable in that jargon. So we have to be able to communicate to others in the language that is meaningful and relevant to them --what it is that we do.

We know. We talk among ourselves all the time. We know about what successes we bring. Unfortunately, we have not done a very good job at communicating our success to the people who were wondering just what it is that we do. If people still don’t know what a case manager does, what we do out there, and who we even are, if there is little recognition of what is a case manager, then that means, in many respects, we have not done our job. We have not communicated sufficiently and in a language that is clear to everyone in various formats.

If a CFO, for instance, is looking at the success of your program, you’ve got to be able to talk numbers. If it’s an employer who is evaluating, “what did I get for these case management services that you sold me,” they have to be able to understand in the language that is meaningful to them as well -- that you got people back to the workplace; that you decreased disability cost and all the associated cost with illness and injury.

This is a…cartoon that appeared in…a New York paper just a couple of months ago. For those of you in the back that can’t see it, it says, “if you have to ask what’s wrong with you, you can’t afford it.”

Now even though we’ve been talking for years now about the cost crisis in our country as it relates to healthcare, we still don’t see the dollar signs quite so visibly in healthcare. We did start to see some of them in today’s presentation, and that is a breakthrough for us. We have grown up, many of us who are healthcare professionals; we have been educated and practiced in an environment where cost was never a consideration.

Physicians and nurses and other healthcare professionals were not number crunchers. When we went into healthcare, we didn’t do it because we were fascinated by the numbers involved. We did it to make a difference. We wanted to make a difference in patients and in case management.

Those of us who were involved and those of you that are charged with overseeing case management services, or those of you that are in third party administrators, that maybe you are contracting out for these services, you need to know what is reasonable to expect from a case management program. You should be asking for some of the things that I am going to be talking to you about today.

Why is it so difficult then when you ask some people, “What did we get from this case management program? Why should we have it?”

And those of you that are trying to create, and get the resources to create, good case management programs, some of you are having difficulty getting the resources that you need to manage the cases that you want to manage.

We heard Dr. Mansheim, in his presentation, talk about how many cases can be managed effectively by case managers, and we hear that all the time. How many is too many?

Well again, going back to the kind of case management I’m talking about --and I’m not talking about benefits management -- I’m not talking about utilization review. I’m not talking about looking at medical necessity and saying “yes” to some things and “no” to others.

I am talking about the management of this truly-complex patient across the continuum of care, in multiple environments -- the kind of management that doesn’t happen in a basic -- what I would call the “disease management program” -- that consists of outbound calls and “Let’s send patient brochures out there and let’s make sure we communicate with the doctor.” These are the kind of patients -- disease management. I look at as a Level I case management program.

These are people that you know, eventually, they are going to have these kinds of problems. So, if you want to have a good basic informational program, and you make sure that all of your diabetic patients are getting baseline information that they know about the consequences of not following treatment plans. They know about HBA-1Cs. They know about their glucometer. They are testing their blood sugars. This is being communicated.

They combine an appropriate diet and exercise regime to keep themselves healthy; those people can do very well with that kind of information. The kind of case management I’m talking about for the complex diabetic patient is the one who has had multiple admissions for non-compliance; who has a diabetic ulcer that doesn’t heal; who comes in to the hospital for grafting; who goes home and maybe develops another cellulitis; who has other kinds of problems; who has retinal problems and who also may be written off by the healthcare community as being non-compliant and some of us fall into that trap as well. We have a non-compliant patient.

Well, these non-compliant patients cost the healthcare system big dollars. Case managers address all of those kinds of problems. That is the case management I am talking about, and those are the kinds of cases that we need to be reporting on…one case at a time. One case at a time, you tell your story, and that is how you build the kind of programs that are really going to make a difference, that are really going to bring savings to the bottom line. I will discuss how we go about doing that.

But going back to one of David’s slides -- I think one of his last slides -- he had a priceline.com slide. He was giving away a hotel room if you participate in this. My story about the comfort level that healthcare professionals do or do not have and how accessible this information is and how important it is for us to have access to the information before we can report whether or not we are cost-effective or not.

If one of the challenges and responsibilities for case managers is to promote a cost-effective outcome, how do you know what is cost-effective until you find out what things cost?

Well, unfortunately for us dealing with healthcare matters, not all of those costs are readily available information, especially as we are going into it, and sometimes we are made to feel that it not our place somehow to question some of these costs. How do we get the information?

Well, in some cases, and we’ll talk about how different the world is -- in most other commodities in our society, you can readily get to the cost information. We’ll talk about clothing, since many of us were shopping over the last couple of days, visiting the mall and on our little sojourn yesterday to some of the shops. It’s pretty easy, and you can tell.

You can go into one of the bargain department stores and see big signs in the window 30 percent off, and you can go in and things are slashed, and the price tags are right there, and they are absolutely visible.

You can go into a moderately priced department store, and you can see smaller signs, more tastefully done, but you can still get to the prices. Right? You can go to a Rodeo Drive or Madison Avenue chichi boutique place, and you go and you try to find the prices there. What do you see? Well, you try to find them and where are they? They are hiding under a collar -- under a scarf. If you go to [a high-end jeweler], you kind of have to peek under the glass and see if you can see that number somehow. But, eventually, you can get to the information.

In healthcare, it is not so easy. Even those of us that are paying a bigger and bigger share, as consumers, for your own healthcare costs, you can’t so-readily get to the information. You don’t see signs in hospitals that are having some difficulty keeping their beds filled saying, “Bring in a friend for an elective procedure, and we’ll do her procedure for 50 percent less,” or, “This MRI, in this part of town, is $200 less. We have to meet our budget.”

We want to get a whole lot in. We still can’t get to that information.

Healthcare, which is the most expensive commodity that our society has, the information, for the most part, is still blinded to us. It makes getting to the bottom line very difficult. How can we make choices? How many of you, you get work done in your home? You have a contractor come in, and you say, “I want these kinds of cabinets and this kind of marble top, and I want this kind of floor.”

And he writes everything up and he says, “Well if you want this, this is how much it will cost. If you get our level B, this is how much it will cost.”

But what happens in the healthcare system?

Those of us that may be having in- and out-of-network benefits and you maybe want to go to the out-of-network doctor because that is the one you really, really want, and that doctor charges $5,000 over what your plan is going to deem reasonable and customary, you are left with a sizable amount of money. Yet, you go and ask that information from most healthcare professionals, if you go and you’re trying to figure out from your surgeon what is that going to cost, most of them will say, “I really don’t get into that. Speak to the person in the business office.”

So we, as healthcare professionals, have been absent from any involvement of that. Those of us that are healthcare professionals -- again we were trained and educated -- it was almost considered, and in many cases was considered, unethical for us to be involved in the cost information -- the price information -- for the myriad of healthcare choices that were out there because, if we knew about what was expensive and what was not, it was felt THEN that, maybe, we wouldn’t be making the best choice for our patients.

Well now we are right in the middle of pricing information. If, as case managers, part of our job is to empower patients with information and advocate for them and help them make cost-effective choices, how can we be a real advocate for them, unless we know what things cost? How can we possibly get some things approved for? Those of you that are in third party administrators or work as case managers -- you work with re-insurers.

Those of you that are in that position and, maybe, you want to make a recommendation to someone that they consider something that is not really in the contract, but you consider it a very cost-effective alternative, how can you ever expect to get anything like this approved unless you are able to present a balanced picture?

If we do this, this is what it will cost. This is what the consequence of this is. If we do this, this is possibly what the savings might be. Those are the elements that you need to bring to the financial decision-makers, so that they can see clearly not only why, clinically, it could be an appropriate course of action, but indeed, financially, it may be a very wise choice.

So we have to kind of, I guess, accept that there are many of us that are still not comfortable in getting information about pricing. And I was very, very glad to see that Karl and our last presenter showed what real pricing information is, because this is how you make these choices. Not the only way you make them, but it’s got to be in the scheme of things.

If a person is going to an in-patient rehabilitation facility, and they have 60 days of in-patient rehab benefits and they have a PPO. It’s part of a PPO network.

Sometimes we think, “Oh, it’s in the network,” and some case managers say, “Well, it’s in the network. We can’t do anything about it. It’s fine. The cost is fine.”

That only takes care of a small part of the problem. A good case manager should be looking at what’s the best use of these available benefits for this person, because not only may they have in-patient benefits, but they may also have a lifetime limit or a yearly limit on rehabilitation costs in general.

Well, if the facility is going to charge $1,500 a day, that patient is going to exhaust the available benefits for a year in a very short period of time. Maybe the better use of the benefits for that individual would be a short course of acute treatment for a week -- 10 days, two weeks -- and then transition that person to a day-treatment program -- a community-based program for a longer period of time, where they have better use and they have control of the dollars and how they will be spent on their care, rather than the providers, even if it is at a discounted rate.

So case managers should be looking at all of those kinds of considerations as they are planning and assisting patients with the selection of care and services that are out there.

So how do we find out this information? Some of you may be contracting case management services out. Some of you may be formulating case management departments in your own organizations, but you still need to get to the cost information. That is a problem that exists with case management today. Unfortunately, there really isn’t a national database out there that is telling us this is the cost of everything and uses this when you are doing a cost benefit analysis report.

So a lot of u, unfortunately, have been hampered by a lack of information, but you, within your own organizations, can certainly get close to this kind of information. Those of you who have affiliations with claims departments -- you can find a hospital bill just as we saw the comparison and analysis today.

If you have a patient with end-stage congestive heart failure and they are admitted to the hospital several times in the course of treatment, you can see what the cost of something like that was. Karl, I’m sure, was able to get that information from a payer who, once they see, and you can partner with organization, once they see that, as you are able to demonstrate the effectiveness of having case management as part of your PPO networks, your second surgical opinion programs, whatever other cost containment vehicles you have out there, you need to have some baseline information.

So I tell case managers, “Get the information. Make it consistent. Make it accessible to the people who are going to need to demonstrate value.”

So you need to have some kind of a database. You need to be able to talk to providers. Ask them. In other conferences that I have been at and maybe you have attended, there are big exhibit halls. You go to the exhibit halls and you find out how much things cost. If you don’t know how much a day in a rehab hospital costs -- and many case managers will tell me, and they say, “Well, I don’t really know what the benefit plans are. I don’t really have access to that. The claims department takes care of that. Customer Service takes care of that. I don’t have the plan contract.”

How can you possibly plan care for a patient unless you know what is in that plan contract? You don’t need that big plan contract, the big contract, but you need a summary plan description. You need to know what is included and what’s excluded.

You need to know how many nursing visits are allowed. What does a home health visit consist of? Is it four hours or eight hours? How can you possibly plan for anyone’s care unless you know what is covered and what’s not? Unless you know, how can you manage your own household? And I’ll bring it back to that.

How can you manage your own household unless you know how much money is in your checking account? So it’s the same thing for each patient that you work with. So those case managers who say, “I don’t get involved with benefits,” you are doing a disservice to that patient, and you are not providing case management services because you can’t possibly plan and organize and give people choices unless they know what is covered and what is not.

So talking to providers, keeping an accurate database, make sure that that is current information. We need to understand that we become overhead costs in our department. Wherever case managers are, whether they are in a hospital, whether they are managed care organization, an employer organization, a third party administrator, we are not there because people are convinced that our involvement will promote quality outcomes.

Although, surely, case managers, if they are really doing case management, will absolutely promote a quality outcome and quality care. As David said, quality care is cost-effective care, and it doesn’t have to be expensive care either. And I’ll talk a little bit more about that.

We need to understand and accept that our role is costing that organization something. We are an overhead. So for us to just expect that, because we are health care professionals and people hired us, that obviously they must know that what we are doing.

That is why case management departments are having such a tough time, in my judgment, getting the resources that they need. That is why some of you that are out there are managing 150 cases instead of maybe 30 or 40, when you can really do a good job. You can’t call it case management if you have a caseload of 100 or 150 people. And so those of you that are in positions of evaluating “Who should I use as a case management provider? What do they call case management?”

Please understand that not everyone that says they do case management are really doing case management -- the kind that I am talking about; the kind that is really going to get the results -- the quality outcomes, the cost saving, and also patient satisfaction, heightened satisfaction. I will talk a little bit more about that as well.

So the accountability aspect of going forward and saying, “This is what I did on this case. This is how I saved money. This is how I promoted a better outcome.”

This has to be part of what it is that we do.

So a cost benefit analysis report, and there is an article and a couple of other handouts; there was an article that was in the Journal of Care Management that actually gives you a sample of a typical cost benefit analysis report. I have been using these. I have had my own company now for 17 years. I started before I had my own company in doing this. Even though I have had customers along the way that had said, “Don’t worry about it. We know what you do. We know you save us money.”

Do not accept that of yourselves or of your case managers either. I do believe that case management needs to be out there front and center. You need to be able to show everyone what it is that your program is doing.

So it should talk about functional outcomes of that improved day-to-day functionality -- the quality of life that that person had. Even at the end of life, case management isn’t a success story necessarily -- only when people get better. Case management can also be successful in allowing people to die a death with dignity.

When you heard, I think it was Carrie Engen, Carrie was talking about bone marrow transplants and some people that get involved in these very aggressive treatments, and it is not allowed for them somehow to say, “No more! Enough! I’ve had enough!”

Case managers need to be able to bring that resolution to the table, that possibility as well. So cost savings, certainly patient satisfaction, use of resources -- these are all very important contributions of case management and, too often, case managers have become unwilling victims. If you will, just show us what you saved. Case management does more than just save money. It does a whole lot of other things as well, and those are the kinds of things that we need to be able to share with our customers.

What kinds of reports should you use? Well, I have been doing this for a lot of years now and, when I first started my company, I was a very small company -- a one-person company, and I had my own caseload, and I would analyze what I did. Part of doing that was, because I wasn’t convinced that people really understood what it was that I was doing, and then as I started hiring staff, I just figured well it took me a while to figure out how to do this and I’d just rather them manage the cases and I would do the savings stuff, because I knew they were nurses and they didn’t like doing any of this stuff. So I started doing it for them.

What I realized, though, was that I would spend weekends at the end of a quarter or the end of a six month period, when my third party administrator clients or employer groups wanted this information, because now they saw where we spent X-amount of money on you, Cathy, what do we get for that? Or third party administrators or stop loss carriers they were saying, “Well this group is coming up for renewal. What did we get for all of this? You know, what are we likely to see in the future?”

So, I initially was doing it for all of my staff and then I decided, “no” As an organization, I was no longer as informed by what that individual case manager was doing on each one of those cases. So I turned it back to them and then had to teach them how to approach this kind of report, which is a very different kind of report format for healthcare professionals.

Healthcare professionals are used to, again, talking in medical jargon and reporting things. Nurses generally, generally, are not real comfortable in tooting their own horn. We take a lot of what it is that we do for granted.

Oh yeah, I just do that, because I’m a nurse or because I’m a case manager, because I’m a social worker, and we don’t take credit for it at all. We’re not good at communicating that, and we’re also not good at communicating to people outside our own professional environment. We are much more comfortable talking to other healthcare professionals.

It wasn’t until I had to sit down, face-to-face with the vice president of a claims department or the CFO of a claims organization, who said, ah, you said just one of the physician presenters, I think it might have been Dr. Mansheim, but I’m not sure, you had these soft savings avoidance charges. What’s that all about? We’re not going to get too much credibility with something like that. Well those soft savings, those so-called soft savings are real savings.

What it has be, though, we have to be able to explain that and to take the person by the hand, and I don’t mean that literally, obviously, but we cannot expect people to know what we necessarily know. We can expect people to understand that, without this case manager intervention, this person would have progressed or would have deteriorated. We have to let them understand, in a language that is comfortable for them, what would have happened in the course of this illness. We have to be the expert in explaining that process but not using the blood gases and T-cell counts and all that kind of stuff, which is way over their heads.

We have to be able to explain to them this is what happens, and I’ve had my share of challenges with people that discount and said. “You said that would happen, and we’re not accepting that as a savings. We’re just accepting anything that you can discount, anything you negotiate. That’s what we’re going to accept as savings.”

So it was very difficult in the beginning. And it means that case managers and anyone that involves case management services, we have to do a lot of public education, and this is what case managers do. We have to explain to people without case management, “This is what would have happened to this person who has been a congestive heart failure patient.”

This is a good example, because there was discussion of it today, and David mentioned it as well -- the non-compliance with pharmaceuticals. Our country is spending billions and billions and billions of dollars for non-compliance with pharmaceuticals. And those of us that are doing case management, we see it all the time with our patients. They take medications. They don’t get immediate results. They take themselves off it. They take Uncle Joe’s. Someone at the union hall recommends something else and then doctors wonder why they are back in the hospital again.

They take pain medication. The doctors say, “Does that work?”

“No it doesn’t.”

What’s the first inclination? Make it stronger. You know, increase the dose or give them something stronger. But what the second question didn’t follow up.

“Did you take it as a prescribed it for you? Did you take it every four hours without fail?” or whatever it happens to be.

How many of you that are in case management, when you do an assessment of somebody and they have hypertension and you ask them what medications they are on, and they kind of tell you, and they say, “What about your hypertension medication,” and they don’t know what hypertension is. You have to say it in the words that they understand. “What about your high blood medication?”

“Oh that. Oh no. I only take that when I get a headache because that is when I know my blood pressure is up.”

Those are the kinds of things that case managers find out about. If you weren’t there, what would have happened? That scenario would have continued, and the patient would have had, what are we seeing now, an increase in hospital admissions. So, great, we have all these clinical paths and critical guidelines, and we have length of stay and Milliman and Robertson and Intequal guidelines, and each admission is fine.

They met the acuity of condition criteria, and we assigned them three days, and maybe they got out, but they had four of those absolutely appropriate admissions in a four-week period of time. So what are we doing here? We’re just checking people in and out of hospitals? That’s preadmission-concurrent review, folks. That’s not case management. What case managers have to do is not just report on things, but be the catalyst for change and to be able to make the difference and then be able to show people.

I always tell my newer case managers when they say, “Oh, I don’t know how to do this. I don’t even know where to begin.”

Begin by, you weren’t even there. I always tell case managers or anyone involved in savings reports, “Pretend like you weren’t there. What would have happened? What would have been the likely course of events? And draw the picture and make it big.”

And there were some really wonderful examples of that today by Karl showing the patient with congestive heart failure -- how expensive each one of those hospital admissions were. Those of you that are in case management, and that’s why this kind of a presentation is so wonderful -- the cutting edge information that we were privileged to be a part of during these last three days -- it gives us the ability to be able to be on the front line as making those as wonderful recommendations.

Had you not maybe been at this conference, you would not have heard some of this wonderful information, and that’s what case management brings to the table. You now are empowered with information that you can bring back to your offices, bring back to your practice settings, really make a difference, really improve outcomes, really save money and we know how much some of these things cost.

So, how often you do these things will depend on what it is you are trying to accomplish. We, in our company, do it for our client groups on a quarterly basis. If it’s a good-sized group, because I don’t want to wait until the end of the year and then have to track back and figure out, “Oh my god, I had hundreds of cases in case management. How do I even begin to determine how much we saved?”

So we take each case as the case is closing, and we take a look back. What happened with this case? What did the case manager do to make a difference, to alter the case of events? How did they affect quality? How did they affect cost? How did they improve function and lifestyle for individuals? All of those are very, very important characteristics.

Avoided charges -- these are some of the terms, and some of those terms have been used. Avoided charges, potential charges, discounts, negotiations, reductions -- what do they all mean and how can you use them?

Well, avoided charges are some of the things that we’ve been talking about. If you avoid, and one of the examples that Dr. Mansheim talked about was a high-risk pregnancy, avoidance of a high-risk pregnancy; avoidance of a preemie baby. All right.

If you in your organization decide and determine that you’ve had an incredible number of low birth weight infants, that should be a clue to you to put in a high-risk pregnancy management program.

The example that I gave you in your handout is that of a high-risk pregnancy. This was a young woman, who I believe she was from the Philippines. She had been a diabetic for 16 years. She already had renal complications. She already had peripheral neuropathy. She already had retinal problems, and against her doctor’s advice, she became pregnant. She lived in a remote part of Oregon.

She was about an hour away from a tertiary care facility. She was also a ferry ride away from that same facility. She was low-income and eligible for Medicaid. She was employed and had private insurance, but because of her economic situation, was also Medicaid eligible. She was not in a good relationship. She had a significant other, who was not her husband, who was verbally abusive to her and would throw her in and out of crisis.

When we first began to manage her, we attempted to do so telephonically, always tried to keep the cost down, and then we realized we really needed to get out and see this woman. We were hearing from her everything was fine. We were hearing from the nurse clinician in the doctor’s office that absolutely everything was not fine -- that her blood sugars were absolutely erratic; that she wasn’t following diet. They had tried to put her into counseling. She would not hear anything of it. She had transportation problems; couldn’t get to the doctor as often as necessary.

So our case manager worked with the high-risk obstetrician, and we put services in place including a social worker, including a public health nurse, including those kinds of support services. We were able to manage her fairly successfully. At the end of her pregnancy, she had a big emotional crisis with her significant other.

She was no longer taking her insulin. She wasn’t checking anything. She wasn’t keeping her doctors’ appointments. Her blood sugars were well up into the 400 range. We were absolutely concerned about not only her life, but, obviously, it was getting crucially important for the life of her unborn child.

It was determined that she was just so out of control that we really had no course of action but to admit her, for her own safe keeping, into the acute care hospital. And that’s what we did. There was no way that we could have kept her at home. She was too far away. If anything had happened, there was no way that we were going to be able to manage her effectively.

So we decided to, and again this is where cost does not drive. Was it a very expensive solution? You bet it was. It was a very expensive solution. Would it have been more expensive to give birth to a child that would have been severely compromised, that we might have lost the mom as well? Absolutely, much more expensive. So even though that was an expensive solution in our judgment, it was the only viable one, from a liability perspective.

Once you know and you are involved with someone like that, you really have to look at the liability. You enter into this relationship and once you know and you see some of the dangers, you have to do something about it. And that’s what we had recommended. And we recommended it, and again we were working with a third party administrator and a stop loss carrier -- a reinsurer. This particular lady had met her spec for the year, and so we had to propose, we weren’t all that comfortable. It was a new reinsurer we were working with, and here we were recommending hospitalization, and it really wasn’t an acute need.

In other words, all of those kinds of criteria that we would have looked at for, is this hospitalization medically necessary? Did it meet those Milliman and Robertson? What was going to be the admitting diagnosis? A social problem?

That, in reality, was the real issue here. We could not trust this lady to take care of herself. She was just so emotionally-fragile, so volatile at this point, that she was a danger to herself. So we proposed this, and we got this accepted. That is how we did it. We had to show what the alternatives would have been. What the cost would have been to admit this individual versus keeping her at home and chancing a problem, and what would we have been facing.

So avoided charges -- especially when you have access to really good information, how much would it have cost?

Take another preemie baby, we know that each day in a NICU is upwards of $3,000 plus, plus all the physicians that visit that individual while they are there. Even with discounts folks, that is a lot of money. So, if you can avoid one preemie baby from coming into the world, that is a lot of savings -- so avoided charges.

Potential charges -- again what might have happened with the in-patient rehabilitation stay that I talked about. If the case manager weren’t involved, and the provider calls up and they find out that there are 60 days of in-patient rehab benefits, what happens? On day 59, they no longer need in-patient rehabilitation -- so great. It was at a discounted network rate. But the more appropriate use of the benefits would have been for a week or two in-patient and then better use of the dollars.

But, had the case manager not been there, would that have gone through? In many organizations, absolutely it would have gone through. So the potential charge, and those are real things, if the case manager had not been there to transition, it would have even maybe met criteria, but the case manager is the one who evaluates individually and the works, collaboratively, with the treating physician, to look at other alternative care sites.

If someone is being admitted to the hospital for chemotherapy and they are admitting for an in-patient stay for chemotherapy, it might be that the doctor isn’t aware that this could be done in an out-patient setting. There are infusion care facilities now. There are home care services’ with oncology clinicians that can monitor and that doctors will trust in terms of sharing treatment responsibilities, and when a case manager is involved, they can propose those kinds of solutions.

They can propose those kinds of alternate care settings. And physicians knowing that and knowing that a case manager would be involved, are more inclined to go along with that kind of recommendation.

So these are the things then, without the case managers involvement, that wouldn’t have occurred. And so they would have continued to be admitted on a monthly basis or every two weeks or whatever the course of chemo is for the three days or whatever at a pretty significant cost even if it is again in the network rate. We could have avoided it completely.

Discounts in negotiations -- those of you who are working with large organizations, you may have networks and good coverage for a number of employer groups, but there are always the cases that you need to get someone. You know, that there isn’t an appropriate network provider.

For prompt-paid discounts, if you have an ability to get through your system, and in some organizations the case managers become partnered with one person in a claims department to expedite these kinds of prompt pay arrangements, so you can get a deeper discount with many providers if you say, “Yes, I can get this turned around in 10 days, two weeks,”

You are improving their cash flow, and they are readily willing and turn to those kinds of arrangements.

Reductions in frequency and duration of services -- again, when you are working with large organizations, they may have PPO networks, and a lot of people feel, “Well, I don’t need to worry about it, it’s in the network.”

The network takes care of the pricing -- pricing alone. It does not take care of frequency and duration. And when you have plans, and if you don’t know what the plan limitations are, how do you know how long that that may be going on?

I still see things today -- rental of equipment that goes on month after month after month. Where was the case manager? Where was anyone looking at this? Why wasn’t this rented for a period of time with an option to buy? Why didn’t someone take a look at some of these things? Why wasn’t this a red flag in the system?

So there are still lots of opportunities today, and I hear from case managers, “Ah, with all these PPO things, I can’t show anyone that I make a difference anymore.”

Well, it may be because you’re not aware exactly of what you are doing on these cases, and that is empowering. Not only do we have to empower patients and their families, we have to empower the case managers that they indeed are making a difference.

So, when you are determining savings, these avoided and potential charges, you are determining savings -- the savings to the payer organization, the savings to the employee as well. Remember we are talking about…if they go to someone out of network and if you brought something, and they have a 20 percent co-pay responsibility or a 30 percent co-pay responsibility, and you’ve made a significance difference in that, not only have you saved the payer organization money, but you’ve saved the employee and his family real dollars as well.

The hard savings, reduced lengths of stay --these are the hard things that no one has difficulty with reducing the cost of care from whatever the retail price is to whatever you were able to negotiate for.

Avoidance of surgery -- some of you that are involved in doing preadmission-concurrent review, you may be reviewing somebody that they are recommending back surgery for. Have they had a second opinion? Are they expecting a miracle? What is being proposed? Did anyone explain what the risks are?

Some of this stuff is still going on. A lot of the barriers, a lot of the restrictions, the second surgical, and the mandated kinds of programs are falling by the board because companies are saying they are too expensive to administer.

It doesn’t mean that you still have opportunities, that we are lacking opportunities to prevent some pretty serious consequences from occurring to patients, only because they are not given the information that they need to know about -- that there are other alternative treatment modalities out there, so avoidance of surgeries through minimalization of complications.

Better healthcare lifestyles -- all of those kinds of things you really make a difference at.

Inappropriate use of services, the rental of equipment -- sometimes people are in facilities, and they are given a list. You know, the occupational therapists come in with the wish list of everything they might ever need in their lifetime, and patients and family they check everything off and, meanwhile, it is sitting in the corner of a room never being used. So it’s the appropriate use of resources out there.

The soft savings -- those are the things again that too many people are willing to dismiss. It is interesting to me, I think, that when our accountant says something or our CFO says something or our legal counsel says something, we believe it because they are who they are, and we assume that they know what they are talking about. But when someone challenges what we say that we’ve done, we immediately buckle under pressure instead of really becoming and showing that we’re the experts.

And yes, this is what would have happened. Trust me. I’ve managed these kinds of cases. We’re to be able to show them an example.

Here a case. Same diagnosis, same kinds of problems, no case manager -- this is how much it cost. This is one with case management. These are the results. So there are very clear distinctions that you can make.

Halting inappropriate care. Preventing excessive treatment. Those are all the kinds of things that we can do.

Where is case management headed? Where are we going with these programs and our services? We certainly need to communicate what it is and what it is not. It’s not benefits management. It’s not utilization review. It is that kind of management that I’m talking about -- those very complex cases with all of these problems. Not one diagnosis -- multiple diagnoses, financial issues, cultural barriers, inability to access care, and then let’s enter the scenario of the graying of America.

We have increasing older numbers of people who we are finding they are still in the employer groups, the employer organizations. It is not uncommon today to see people well into their 70s, who then become ill, who have spouses who are ill. They are still working. We’re going to see growing numbers of problems, and these are people who, years ago, when every one of our families kind of lived pretty close together, it wasn’t so much of a problem when Mom and Dad got old.

Now it’s really a problem. Their kids have moved all over the place. Their spouses died. They are isolated from communities. And then what happens? We are entering the world of technology that they are so absent from. We do hear stories with AARP on how many senior citizens have access to the Internet and are using it, but we have growing numbers of people, growing numbers, who have no idea what it is. They can’t use the phone systems. They are getting voice-automated systems.

I was talking to somebody either last night or the night before in one of our networking opportunities, and I am getting in the age bracket where I pick up the phone and I get an organization and they have six menu options and I’m listening to all of them and now I have forgotten what option one or two was, and maybe that was the one that I wanted. So what do I do, I hang up the phone and I call it again.

And now I’m writing them down, and I’m saying, my problem doesn’t fit into any one of those. And you try to push zero to see if you can get a live person on the phone, and a lot of the systems now have gotten savvy, and they say, “Inappropriate response, I don’t recognize that command.”

So you can’t get a live person. So what of the people who absolutely need case managers? What are they to do in these situations? Case managers do make the difference, and we make the difference by getting them access to care and services in that time element that they need to make these important choices, and that’s a real important component that we bring.

And too many organizations that I see attempt to have case management programs to meet all the needs of everybody. Some consulting group has come in, and they say, “You need to manage all of these people.”

You can’t possibly manage all of those people. You really need to be able to identify the kind of folks that you are going to be able to make a difference in that you’ll say, “Yeah, case management, this is how we can help in this situation.”

And you do it, not hundreds of cases all at once, but one case at a time. One case, perfectly, how you do it, and then grow your program incrementally.

The accountability of case management actually makes you a player at the table. It makes case management a real important component in the health care or administrative services that you provide to employer organizations.

When you can say that we have the ability, employer groups, to identify through the people that we are working with, whether you outsource it, whatever you do, that we have the ability to identify at a very early opportunity the kind of people…those ratios that you heard Dr. Mansheim talk about as well, whether it is the 20 percent of the people that are spending 80 percent of the dollar or five percent of the people that are spending the 90 percent of the dollars, those are the folks. They have bright lights all over them. We need to find them, and we need to manage them.

We need to capitalize on the trends, the issues that impact illness and wellness, and case management does offer that opportunity. We’ve been spending a lot of time managing the big healthcare problems, but, by doing that, we have also helped create some of those disease management programs because we are seeing, case managers see, this is what the case looks like because they had none of this information.

If we can put in these earlier wellness programs -- the smoke cessation programs, the healthy baby programs, all the programs that cost a minimal amount of dollars -- case management can have a major impact on those kinds of things as well.

The challenges and opportunities, obviously, that we all face, no matter where we are in corporate America, we have multicultural concerns and technological advances and growing rates of illiteracy and, of course, the graying of America -- the vulnerability of increasing numbers of elderly people who have no one to turn to. These are the folks that we really can be managing and assisting.

We can turn these projects into real programs. We need to become lobbyists within your organization, within the political community, within your own neighborhoods. How many times I have spoken at conferences and asked, “You know, if I speak to a whole bunch of case managers, how many of you here have families that haven’t a clue as to what you do if you are a case manager?”

And the majority of people usually raise their hand. They understood what they did when they were a nurse or social worker and wore that title, but as soon as they started with this title of case manager, no one seems to understand what they do. Yet, clearly, we know that these kinds of services make a real difference, make a major impact and, still, it seems to be the best kept secret out there. And we need to publicize that a whole lot more. One person really can make all the difference.

Case management -- it’s not a perfect science. We know that. We are working within CMSA, URAC, the Commission for Case Manager Certification. We are trying, very hard, to address the concerns that people who use our services have. We need to get research completed, as David so well spoke about in his presentation. We need to have believable research, credible research, that actually shows that case management makes a difference. We are in the midst of that; we still have not completed that.

The resources that we have are not endless out there. We’ve got to make better us of them.

We can hear just this morning, if we continue to progress or regress, depending on how you are looking at it, the number of people who may need the kind of technological advances; we’re not going to have the resources to provide. So we need to manage, right now, that which we do have, so that, what we need in the future, will be there for us when we get to be that age.

We are part of the solution. Case management programs are to address those at-risk populations; to implement disease management programs that earlier stratum, if you will.

There are just a couple of closing remarks. Since I was the end speaker today, I wanted to send you home, hopefully, with some words of encouragement.

So to be successful, go where the action is. That may be a little bit too much action and that’s maybe what you are going to be feeling like when you back to your offices on Monday. We need to act now. This is the time.

Change has considerable psychological impact on the human mind. To the fearful, change is threatening, because it means things may get worse. To the hopeful, change is encouraging, because things may get better. To the confident, change is inspiring, because the challenge exists to make things better. Opportunity is where you find it, not where it finds you. A determined person is one who, when they get to the end of their rope, ties a knot and hangs on.

You can miss opportunities; you can cut off growth; you can lose your job OR CHANGE.

Here’s another…cartoon which says, “I prefer what was to what now is, because what was wasn’t now isn’t.”

And that really underscores change and wouldn’t we love to maybe, in some respect, go back to when things were more complex, but that is not possible and truly the opportunities, many more opportunities to improve things, exist in an environment of change. And although that is very difficult for all of us to cope sometimes, when change is happening more rapidly than we can stabilize things, it really does present us with many opportunities.

Don’t focus on the minutia, and this is my all favorite cartoon. It says, “Don’t spend your time stamping out ants when elephants are coming over the wall.”

What we, in our case management programs, need to be mindful of, we spend so much time looking at the small things that don’t matter and analyzing that data to death. Meanwhile, the big cases are out there. The big cases that need this kind of intervention that can be helped, that can have better lifestyles, that can return to their homes and communities, that we can save your companies real dollars, society real dollars and really make a difference if you find the elephant coming over the wall.

One person really can make all the difference. Each one of you can make the difference.

We have about maybe five minutes for questions.

Q:  We work for a TPA, and I think we had talked to a couple other people that were having the same issue happen. We are being contacted by reinsurance carriers, by employer groups, by outside individuals, but really they are part of the claims paying system, wanting additional information or more-or-less micromanaging, because they want to know what’s going on, because of such the high cost of healthcare.

Mullahy:  Right.

Q (cont.): So we find ourselves being very frustrated in that. I mean; they get monthly reports. Sometimes the people we talk to aren’t getting them. We are really getting cautious about who we are giving what to because of the confidentiality of the patient.

Mullahy: Absolutely.

Q (cont.): And I don’t know if that is happening, we had talked to someone else at a table, and it’s happening to them to. They’ve got a preemie baby, their case management; someone wants updates every two weeks. That baby is not going to go anywhere in two weeks. Are you seeing that?

Mullahy: Absolutely.

Q (cont.): What are you doing?

Mullahy: We see it with our customers, and some of them may be involved, now, with case management programs for the very first time. We find that, when employer groups are in fully insured organizations, they weren’t involved in any of this. When they become self-funded or partially self-funded, they become more up-close-and-personal, because its absolutely their dollars now. So, they are insecure about a whole lot of things. We need to reassure them, and we need to educate them on what we do, what we can and cannot share with them because some employer groups that I contacted directly, by CFO’s of organizations, by human resource people, they say, “Because they are my dollars, I have a right to that information.”

They don’t know what a position they are putting themselves in by -- if I were to give it to them, and I never would -- by having that information, because having that information allows them to discriminate in hiring decisions, in firing decisions, and I don’t think, legally, they really know or understand what a risk they put themselves into for getting that information.

What you kind of have to do when people are saying “I want updates every two weeks, what is your concern?”

You kind of have to say, “I hear your concern. Why do you want that information? What are you concerned about?”

Sometimes it is a broker who’s calling. The group is coming up for renewal. It is the underwriting department.

You always have to find out, who’s calling, what’s their agenda, why do they need the information. And, if you’re not sure of whether or not some of the information is appropriate, and some of the information absolutely is appropriate -- there are underwriting departments that may need to know before they can price a group out -- and I will defer to the reinsurance experts here -- but I have worked with a good number of stop loss carriers, third party administrators, brokers, and underwriters, who they say we want to know who the big cases are.

Now they have a need to know. If you are in this kind of business, it is risk assessment. It is risk management. Where are my risks? They don’t need to know, “It’s John Jones. He has a wife who is 32 years old. Her name is Judy. This is her diagnosis. Here are all of her treatment plans.”

They don’t need to know that. You need to find out what it is they need to know. I’ve had employers that say, “You know, I hear you do reports, I’d like those reports too.”

Well, in my company, we use two kinds of reports. We do our clinical, initial evaluation progress reports, which are very case management-focused. “This is what we’ve done. These are our recommendations,” and they go to the case manager liaison person that we are working with or the third party administrator claims department. And it’s for their use.

It’s for use in if we needed to make exceptions or alternatives to the plan contract. It documents exactly what we were doing and what we were recommending.

Those cost savings reports that I was speaking about here; those are the business aspects of case management. And those reports, in my judgment, if you saw the way they were prepared in the handout, I see nothing wrong with handing that over to a Claims Department -- to an employer group. If you notice, all the information is kind of blinded out, and the bigger the employer group is, there are ways of securing the information so that the employer says, “Okay, this is good information.”

Or the broker says, “Yeah, I think that this is a good thing to recommend to our clients, because I can see how it would save money.”

What we also do, we do patient satisfaction surveys. I talked about the cost benefit reporting, but we do patient satisfaction surveys. We have a letter, and we have a survey that we send to each one of our cases as they close or, if they are open for a protracted period of time, as some of our infants and longer term cases are, and we survey those people periodically. I use it as a marketing tool to show an employer group, “Here’s the savings report.”

Now, in that report, the handout that is in the handouts today, in that article, that is just one case report. We prepare a summary for each employer group or for each third party administrator, showing all the employer groups. So we show the savings overall from our involvement, but we also show them of all the cases that we worked, and these are the number of people that we surveyed and 95 percent approved of this involvement, would recommend it to others, and, in fact, if it weren’t covered as part of their benefit plan, 85 percent would pay for it themselves. Those are very powerful tools to use in documenting the effectiveness of this kind of program.

So to answer your question, yes, you are going to get questions all the time, and everyone is looking. It’s because everyone is into the outcomes and accountability stuff. Show me what you’ve done for me lately. They have a right to certain information, but they also need to understand, and you’re right, that preemie baby, my calling you every two weeks, it’s not going to change the course of events here. But they don’t know that. So you have to find out what is their reason? What do they need to know? And then work with them on that. Okay?

Q: I, too, work for a TPA, and we continue to bang our heads against the wall when we try to get approval to open case management services when they haven’t met specific. You alluded to that, but can you be any more specific as to how to put what we do in layman’s terms.

Mullahy: Absolutely.

Q (cont.): We struggle with it all the time.

Mullahy: Our company provides preadmission-concurrent review and case management services to our corporations, our corporate clients, nationally, and they include union health and welfare plans, third party administrators, reinsurers directly. In our preadmission-concurrent review program, we do not use that tool, and I say it’s a tool. We don’t use that tool to approve or deny days. It’s a preadmission notification advisory program. I use that tool, and we created it, and we used some of the guidelines that are out there in terms of lengths of stay, etc., etc. We use that tool, because I absolutely know that every high-cost, complex patient that eventually will need case management goes through the door of that acute care hospital.

And, if I watch each one of them as they are coming through with professionals, we have nurses that are actually following that patient’s course of treatment in the hospital, and, sometimes, the very day they are admitted, if they are admitted as a pediatric case with a brain tumor, I know this isn’t going to get any better, more than likely. And so we have a case management advisory form. We make sure that, when we’re developing a program, if you’re an outside entity and you work with a third party administrator, you have to set up the game plan, I guess, to begin with.

You say, "We may find a case for case management." You need to find someone who understands number one -- what it is at the third party administrator level. Not everyone who is put in a position may necessarily understand, but you have to be able to also tell them, “This is why we are recommending case management,” and not using the medical terms that you are comfortable with.

But say, “This person has a brain tumor. We have learned that it’s malignant. They are going to be on very powerful chemotherapy. It is going to compromise their immune system. The likelihood of their developing infections is good. And, by a case manager being involved, this is what we hope to be able to do. We will work with the patient’s family. We will work with the treating physician.”

That becomes almost a no-brainer. People can understand that.

You can’t just expect to say, “This is the patient. Here they are.”

Throw it in their face and have them say, “Oh yeah, we trust you.” After a while, they will begin to understand and say, “Well, if they recommend it.”

When I first started doing this, I had proof. You have to prove that you know what you’re talking about. You have to prove that you are just not going to manage everything.

In fact one third party administrator that we were working with -- and this is before we did the preadmission-concurrent review -- I wanted to do it, they saw it as a way that they could make money. So they were going to do it and charge the clients for it. We agreed that they would send over the cases that were likely to need case management. They would send them over to us, and then we could continue reviewing them in the hospital. But they thought the majority of cases didn’t need this stuff, so they wouldn’t send us everything.

They didn’t send us -- I’ll just give you a real easy example. Someone was admitted to the hospital with abdominal pain. That was the admitting diagnosis. Well the pre-cert department in the TPA said “Abdominal pain, that doesn’t need case management.”

Well, the abdominal pain turned out to be a ruptured intestinal obstruction, which turned out to be a horrendous infection, which turned out to dehydration pneumonia, and all of us sudden, the next call that came to the Claims Department was, “We need home care services and TPN when the person goes home.”

Well, that demonstrated to them.

Or the pregnancy that they said was a normal, vaginal delivery. That doesn’t need case management. Well, the mom went home, but they didn’t find out, until six weeks later, that the normal vaginal delivery was of a preemie baby that weighed two pounds. So, those are the kinds of things. You have to be able to kind of show your story, not push it in their faces, but in a way that makes it reasonable to them -- that you are just not out to spend money and manage everything but that there is real good reason to do so. Does that help?

Anybody else? I will be here for a while longer if any of you have any burning questions that are keeping you here and not on your way home or enjoying the city. I would be pleased to entertain them. Thank you again.