DorlandHealth

Editor in Chief Anne Llewellyn sits down with Dr. Dennis Robbins, MPH, an ethicist whose work touches on quality, health law and health policy, to talk about medical utilization management, denials, and the potential impact of the burgeoning area of comparative effectiveness research.

Q: What is one area of medical management you see changing as a result of health care reform efforts?

A: One of the most controversial areas of health care arises when coverage for medically necessary treatment is delayed or denied. The logic of denial is based on deflecting services or interventions that are not “medically necessary,” which is good if it protects patients against overtreatment and reduces waste. It is a negative when denying becomes an overzealous and medically unjustified crusade fueled by spurious denial criteria. Hopefully, shifting from denial-based approaches into validated, data-driven, evidence-based and comparative effectiveness standards will significantly decrease unfounded denials while ensuring the integrity of medical utilization management.

What new model do you see as a way to improve utilization of health care resources?

Reform initiatives to remove restrictive rating criteria and pre-existing illness exclusions as well as such “new” models as comparative effectiveness (CE) will play an increasingly important role in rethinking exclusions. CE is positioned to help determine which treatments are best and most appropriate. By creating a repository of evidence to determine optimal treatment among comparative options, past determinations of “medical necessity” will become more scientifically grounded and less whimsical.

To explore recent and potential changes to the practice, we consulted with Garry Carneal, JD, MA, the president and CEO of Schooner Healthcare Services, LLC, to talk about the impact of social networking and wireless communication on case management. Garry is also co-chair of the steering committee at the Population Health Impact Institute.

Case In Point: How are advances in technology changing the landscape of case management and what technology specifically is leading the way?

Garry Carneal: According to several reputable resources, more than 2.5 billion text messages will be sent today in the United States. Texting has now become the most prolific form of mobile communication in the United States, overtaking cell phone calls. Howard Rosen, the founder and CEO of Life:WIRE, which is an interactive health management solution that uses text messaging and email, recently noted that “text messaging is taking off not only for younger Americans, but over half of all Americans who send and receive text messages today are 35 years and older.”

This is a unique development. And now dozens of text messaging platforms for health care are being offered in the market, running on everything from smart phones to basic cell phones, to improve communication channels, increase efficiencies and better engage individuals to achieve better health outcomes, according to Rosen.

We pose a series of questions to Kathy Craig, MS, RN, CCM, president of Craig Research Continuum, to learn about the growing set of tools surrounding caseload issues, including the latest on acuity methodology. Ms. Craig, who serves on NCMN (Canada) Board, PCM Editorial Board, and CMSA’s Caseload Work Group, can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Q: As someone involved on the frontlines of tackling the caseload quandary, what are the most important issues that need to be addressed and steps that need to be taken?

A: What frontline case managers ask me to solve is bringing equity to case management caseloads quickly, fairly and dependably. Supervisors and business leaders ask for a method that is objective, reportable as data, and reproducible in a way that confirms validity.