Self-Funded or Not, Brokers Should Know the Way Through the Care Management Maze

Two-thirds of employees in the U.S. who are covered under an employer sponsored health plan are also covered by some form of a self-funded health program. There are several advantages to self-funding a health plan, but the primary reasons employers choose this option is to lower costs and increase financial control. Self-funded plan designs can include strategies to monitor utilization, steer care to discounted provider arrangements, and assure appropriateness of care.

All of these strategies can encourage wellness and provide incentives for wise utilization of care, but many health care services offered under the heading of “care management” can be daunting to decipher. Every broker should understand the terms of these services in order to guide clients through this complicated system. It can be unclear what programs are in the scope of services included and whether these programs are actually cost-effective for a specific employee population. The experience of understanding care management can be like trying to navigate through a maze. Not all care management programs will lead you to the most appropriate outcome and some may leave you retracing your steps with the client to navigate a better path.

When working with a client, you may be expected to know the way through the labyrinth of care management to sell a health care plan and to answer a client question about their employees’ care. The key to this maze is to know that each care management service has different interaction levels with participants and different costs associated with each program. This article will help you navigate the care management maze more effectively to help you and your clients identify the most cost-effective care management solutions for an employee population.

Care Management

There are several care management programs and services an employer can provide to the employee population. These services include primary care, wellness, disease management, utilization review and case management. Depending on the health of the employee population, some employers may decide to implement all or only some of these services since all of these options are very specific in their application to patient care. While care management options like wellness and disease management programs offer preventative solutions to curb future health risks, the addition of utilization review and case management programs may be a cost-effective option for an already unhealthy population. Since each person needs different interaction levels of patient care, every case through the care management maze will be unique.

Primary Care Physician

The primary care physician or health care provider is the first care manager an employee goes to when they have a concern about their health. They utilize their provider for annual physicals and health risk assessments like cholesterol and bone density screenings. A good primary care physician might recommend lifestyle changes, such as dietary adjustments or exercise programs based on test results or patient concerns. This might lead employees to the next turn in the maze – a wellness program.

Wellness Programs

Wellness programs are designed to prevent serious illness and get people on a path to becoming, and remaining, healthier. Individuals must often make significant effort to change particular habits: to improve physical conditions like giving up smoking, losing weight, exercising more, and having regular medical check-ups, especially for mothers-to-be. A wellness program often involves coaches who are knowledgeable and experienced in illness prevention. Coaches may encourage weight loss, for example, to prevent a person from developing diabetes, a serious and debilitating disease which can be life-threatening for the individual and costly for the employer. Hopefully, a wellness program for a healthy employee population will be the last turn in the maze of care management.

Disease Management Program

When a medical condition is diagnosed, especially a high risk condition such as asthma, high blood pressure, high cholesterol, diabetes, or cancer, the employee – now a patient delves further into the labyrinth. The primary care physician may recommend that the patient take part in a disease management program designed to keep a disease from becoming more severe. Nurses trained in disease management will work to ensure that patient is taking appropriate medications as directed by the physician; make sure the patient goes to the doctor for exams on a regular basis; and help the patient manage new behaviors and routines to lower the chance of the patient becoming more ill. For example, by treating and managing high blood pressure and high cholesterol early and regularly, most people can avoid heart attacks, strokes or diabetes. When not treated early, a person will most likely end up with an elevated disease state, often accompanied by hospital stays, incapacitation, and higher claim costs.

Utilization Review

At this point, the patient’s condition is usually subject to utilization review which determines whether the physician’s proposed treatment is deemed to be medically necessary. A variety of networks address not only the medical necessity of treatment, but also whether the treatment is an accepted medical practice, not experimental or investigational, and if it is a covered benefit under the patient’s plan. Utilization review is usually undertaken by the medical network. Once determinations are made, the patient and health care provider are advised accordingly.The treatment plan is approved and some patients may enter the hospital.

Case Management

The next leg of the maze now comes into play. Case management is a short term program most often associated with inpatient stays at hospitals. The goal is to help patients recover and be released from the hospital quicker or receive care in a non-hospital setting, such as a rehabilitation facility where the costs are lower, but at a level of care appropriate for the patient’s medical condition. For example, a patient who has a heart bypass operation will be cared for initially in an intensive cardiac care unit with constant monitoring. At some point in the recovery process the patient is usually moved out of intensive care to a room where less intense monitoring, and fewer hospital staff, is needed. Case management nurses track the patient’s improvements and recommend further step-down care in the hospital or plan for a patient’s discharge to a rehabilitation facility or transfer to the patient’s home. Case managers work with physicians, nurses, the patient, and family members to arrange for the best and most cost-effective care plan. It is important to note that all care management options are voluntary and require patient approval. Case managers, for instance, cannot move a patient to a less costly option if the patient or the family does not approve it. The patient makes the final determination whether to seek care or follow suggested options.


Every level of care along the maze is accessible when it is chosen by the patient and not all paths through the maze lead to the same outcomes. While each program is unique, the decision to implement all or some of these care management programs is a decision that you and the employer must make to determine the most appropriate and cost-effective care services based on the overall health of the employee population. Third party administrators are experienced in providing support to brokers in your ongoing efforts to help clients control costs and manage their self-funded health plan.

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