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WHEN EVALUATING a managed care organization's plan, typically 9% to 10% of a plan's membership have serious chronic diseases, such as diabetes, congestive heart failure, or asthma. Usually, these patients consume one-third of the plan's health care expenditures. The goal is to prevent expensive hospitalization and emergency department visits (Goldstein, 1998). Disease management programs offered by health systems and other health care enterprises provide programs to assist individuals with managing their chronic disease.
Another one-third of a plan's health care expenditures are consumed by 90% of the membership who are the healthiest members. Typical health problems are minor in nature (for example, cold, sore throat, ear pain, abdominal pain). The goal for this group is to reduce demand for primary care physicians and emergency departments by providing other 24-hour per day alternatives such as health medical call centers (Goldstein, 1998). Medical call centers including triage, referral, appointment scheduling, and other services are referred to as demand management.
The remaining 1% of a plan's membership experience serious, complicated health problems that require hospitalization. These members account for the remaining one-third of the plan's health care expenditures (Goldstein, 1998). Episodic care management is indicated for this group to both educate the patient/family about treatment options and to refer the patient to appropriate levels of care that may be less costly than hospitalization.
In environments with high penetration of "at risk" and capitated managed care contracts, it is critical to manage demand, acute episodes of serious illness, and chronic diseases. Moreover, the value for an integrated delivery system in the future will be its ability to improve the health of the population and to drive cost efficiency. Integrated care management will be the cornerstone of an integrated delivery system's success. The definition of integrated care management developed by KR Associates, a health care consulting firm, is:
A collaborative system of achieving and maintaining optimal member health status over the care continuum by effectively providing, integrating, coordinating, monitoring, and evaluating health care services for the purposes of meeting individual patient's needs, and for promoting quality and cost-effective outcomes.
Integrated care management is the proactive coordination of patient care across the continuum and from any point of care within an integrated delivery system. The goal of integrated care management is...