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Careful use of nurse case managers can improve outcomes

Careful use of nurse case managers can improve outcomes

Although they are an added expense, nurse case managers can significantly reduce the duration and cost of workers compensation claims by guiding injured employees' medical treatment and return-to-work efforts, experts say.

However, nurse case managers also can increase overall workers comp costs if they are brought into a case too late or do not follow evidence-based medical protocols for managing injuries and disabilities, experts warn.

The key, workers comp experts say, is to establish criteria up front about when and how to use nurse case managers and continuously monitor their activities so they do not bill more hours than necessary to close a case.

“Case management is like a spice in a recipe. We don't want to use too much or too little,” said Gary Anderberg, Philadelphia-based practice leader for analytics and outcomes at Broadspire Services Inc., a unit of Crawford & Co.

A nurse case manager's job is to facilitate workers comp claims by advocating for the injured employee's medical needs and ensuring a continuous flow of communication among pro-viders, claims adjusters, the claimant and the employer.

In some cases, nurse case managers provide “triage” immediately after an injury is first reported to ensure the injured employee gets appropriate treatment and is positioned for a speedy recovery. At other times, they work in the field, accompanying patients on physicians' visits, making home visits to ensure injured claimants are appropriately managing their care, or meeting with supervisors to arrange for modified duty or worksite modifications to enable the claimant to return to work.

While most workers comp medical case managers are registered nurses, cases involving complex or catastrophic injuries may have doctors as case managers. Some insurers and third-party administrators provide their own nurse case managers, while others outsource the function to firms that specialize in workers comp case management services.

Medical case managers typically bill by the hour, with fees ranging from $80 to $125 per hour. In triage situations, medical case managers generally charge a flat rate, averaging about $80 per call. In some situations, case managers are paid a flat rate for “task assignments,” such as accompanying an employee to a doctor's appointment or evaluating an employee's worksite conditions.

Even though they are an additional expense, nurse case managers have reduced overall workers comp costs in most cases, industry experts say.

For example, at Boston-based Liberty Mutual Insurance Co., nurse case managers have shaved an average of $6,100 off medical and indemnity costs for the workers comp claims on which they were involved, producing a return on investment of 8-to-1.

“There are certain cases where having a medical resource could truly have an impact,” said Maureen McCarthy, senior vp of work comp and managed care at Liberty Mutual. “Say someone injures their knee and has no other medical conditions that could impede recovery, and the provider is treating within medical guidelines. We probably wouldn't assign a medical resource to that case. But if you take the same facts with a person who is 100 pounds overweight or who has co-morbid complicating conditions, that would get a medical resource.”

Liberty Mutual uses a variety of medical resources based on individual claim facts, ranging from telephonic case managers who provide initial triage to field nurses who meet face-to-face with injured workers throughout their recovery. Regional medical directors based in all of Liberty Mutual's claims offices work on cases that require additional medical expertise, such as catastrophic injuries, Ms. McCarthy said.

Case managers also have reduced the likelihood that a claimant will seek help from a lawyer, said Rebecca Shafer, president of Amaxx Risk Solutions Inc. in Hartford, Conn.

Litigation rates dropped by one-third in a nurse case management pilot program administered by MEDSTAR Medical Management of Long Beach, Calif., said Pam Guiles, vp of operations. In addition, the duration of cases was halved, she added.

In general, only about 10% of all U.S. workers comp claims use nurse case managers, according to experts. However, the number has grown in recent years as a result of the introduction of nurse triage programs.

With such early intervention, the nurse case manager performs an initial evaluation to determine if self-care is sufficient or if a claimant should be directed to a health care facility. Based on the extent of the injury, a nurse case manager also will decide whether nurse follow-up is necessary, said Emil Bravo, executive vp at Gallagher Bassett Services Inc. in Itasca, Ill.

Under GBS's model, “a triage nurse reviews every claim that comes into our call center and, based on initial criteria, determines whether it should be referred for case management,” Mr. Bravo said.

While most insurers and TPAs use prior claims experience to determine when to assign nurse case managers, employers also can make that decision. They may also use predictive modeling (see box).

For example, Denver Public Schools, which self-insures its workers compensation program for its 12,500 employees, decides case-by-case whether to call in a nurse case manager, said Stephen Finley, director of risk management.

“A case manager on the front end saves us money by providing an opportunity to direct care early,” Mr. Finley said.

At other times, the school district will involve a nurse case manager if a claimant is showing little or no improvement, said Karen Bright, the district's workers comp supervisor.

She cited a recent claim in which an employee slipped on spilled milk in a school cafeteria and sprained her knee. “It just kept getting worse and worse,” Ms. Bright said. In fact, the claimant blamed a later fall down stairs in her home on her sprained knee. After the nurse case manager was brought in, “we learned that the person was going through a divorce, and there were other things going on in her life. The injured worker was trying to create her own treatment.”

Regardless of whose decision it is to use a case manager, there are times when they can increase overall workers comp costs, experts warn. “If it's not managed, it could be a significantly growing expenditure,” said G. Bryan Thomas, CEO at Cannon Cochran Management Services Inc, a TPA based in Danville, Ill.

For example, field case management in a traumatic brain injury case could amount to $3,000 a month or more, he said.

“There's an incentive for the case manager to bill as many hours as possible,” said Joseph Paduda, a principal of Health Strategy Associates in Madison, Conn.

To make sure the case manager doesn't get carried away, claims adjusters like those at First Niagara Risk Management Inc. in Buffalo, N.Y., usually serve as gatekeepers, requiring nurses to conduct an initial triage and then report back with recommendations, said Dan Conley, vp and corporate qualifying officer.

“If it's plausible and makes sense to the adjuster, then he or she may approve. They don't just give nurses a "blank check,'” Mr. Conley said.