Like Utilization Management, a third party, other than the healthcare provider and the patient, becomes involved in the treatment process and is necessary for Medical Case Management. While Utilization Management involves only the provider of medical care services, whether hospital, doctor or specialist, Medical Case Management intervenes with both the provider and the patient, taking a much more active role in the treatment process. Utilization Management is generally a remote activity achieved by paperwork, computers and telephone, with occasional on-site review of medical records and bills. In Medical Case Management, a lot can also be done by telephone: gathering information, arrangement for treatment, etc. It is necessary, in most cases, for a medical care manager to personally communicate with all interested parties in the treatment process; the providers, the patient, and the patient’s family.
Medical Case Management should not be used for routine cases as it is not considered cost effective for commonly used procedures and treatments. Statistics indicate that 40% of medical care costs are attributed to 3% of the patients – those very seriously ill or injured. 40% of medical costs are attributed to 17% of patients with chronic illnesses. Applying Medical Case Management to just 20% of the patients allows over 80% of medical care costs to be controlled. (NOTE: These statistics illustrate the “Pareto” rule, that states that roughly 80 percent of most events can be attributed to approximately 20% of their causes).
Determining just how cost-effective Medical Case Management is, or can be, is difficult to determine because catastrophic and chronic medical problems involve longer periods of time, called “long-tail claims” in insurance parlance, than other medical care which is usually of a short duration. Therefore, in catastrophic and chronic cases, the cost savings can only be projected. People rarely take such projections into serious consideration, as there can be too many events that can completely destroy the estimation. Therefore, there is really no way to “prove” that the medical case managers can actually effect such savings. However as a larger data base is created with experience, it appears that such savings are actually realized.
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