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The Case Management Approach

October 11, 2012 International Centre, Mississauga, ON

Suzanne LepagePrivate Health Plan Strategist

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Disability vs Drug Case Management

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Disability Management• Workplace injuries, illnesses, and accidents are costly to both

employers and employees • The more effective employers are in managing health related

absences the greater the potential savings

Disability management programs:• Facilitate early return to work without jeopardizing the

health of the employee. • Maximize treatment while minimizing lost time and the

associated human and financial costs to the employee, their family, the employer and society.

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Disability Case Management• Single point of contact for employee and employer

• Co-ordinate all aspects of claim - adjudication, recovery and return to work.

• Ensure claims managed consistently and proactively• Work with claimant and physician(s) to identify

functional abilities• Develop, coordinate and monitor treatment plans

(including preferred medical and service providers)• Partner with employer to ensure safe and timely return

to work• Recommend appropriate workplace medical

accommodation• Limit payment or decline claim when:

• patient does not cooperate with case management• adhere to their treatment plan

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Drug Claims Case Management • Review physician's proposed treatment

• Compare treatment to accepted medical guidelines

• Identify alternative treatment options

• Coordinate treatment ( incl. preferred pharmacies and infusion clinics)

• Provide coaching and support to patient• Monitor patient’s adherence to treatment plan• Compare health outcomes to medical guidelines

to objectively measure effectiveness:• Alternative treatment if no outcomes

• Limit payment or decline claim when:• patient does not cooperate with case management• adhere to their treatment plan

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Potential Advantages and Disadvantages

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Potential Advantages and Disadvantages

1. Plan Member / Patient2. Physician3. Plan Sponsors4. Pharmacists5. Pharmaceutical industry

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Potential Advantages Potential Disadvantages• Value added benefit -

personalized support

• Education on treatment alternatives

• Improved health outcomes

• Access to medications

• Drug plan sustainability

• Medication choice limited

• Treatment plan may be altered

• Access to medication delayed

• “Step therapy”

• Delays = disease progression

• Confusion between insurer and pharma programs

• Required to switch pharmacy

Plan Member / Patient

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PhysicianPotential Advantages Potential Disadvantages

• Insight into treatment alternatives and relative costs

• Improved communication from payer on individual coverage decisions

• Improved forms and streamlined processes

• More time spent on administration

• May limit therapeutic options

• Case manager “second guessing” treatment plan

• Confusion on process and coverage

• Confusion between insurer and pharma programs

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Plan SponsorPotential Advantages Potential Disadvantages

• Cost management • Drug plan sustainability• Improved ROI on medication

$• Improved plan member

health outcomes• Improved productivity,

reduced absenteeism and disability

• Plan member complaints and dissatisfaction

• Delays could result in disease progression in plan members

• Reduced productivity, increased absenteeism and disability

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PharmacistPotential Advantages Potential Disadvantages

• Pharmacist more involved in patient care

• May lose business if patient required to switch from their local pharmacy to payer/case manager pharmacy

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Pharmaceutical IndustryPotential Advantages Potential Disadvantages

• Opportunity to develop partnerships and integrate programs

• Reduced sales • Program overlap • Process and coverage on

specific drugs not clear

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Evaluating Case Management

1. Plan member/Patient

A. Outcomes – measurably improved health?

B. Satisfaction/perceptions?

2. Plan sponsor

A. Savings? Drug plan costs vs cost to administer program?

B. Change in productivity, absenteeism and disability?