Coordination of Care for Persons with Disabilities Enrolled in Medicaid Managed Care: A Conceptual Framework to Guide the Development of Measures. E. Care Coordination And Utilization Management


One reason that the term "case management" has a negative connotation to some is that it has become associated not with ensuring that people get what they need, but rather to ensuring that they get ONLY what is absolutely essential. Indeed, some insurers and employers began to implement "high cost case management" programs specifically to reduce utilization and costs associated with complex and difficult cases (Alexandre1990). Sometimes these programs recognized that early interventions and the delivery of non-traditional (read social) services could both reduce costs and improve health, functioning and even autonomy. All too often, however, they were no more than especially aggressive utilization review and management activities.

The relationship of care coordination and utilization management is important. Many on the panel feel that in order for care coordinators to be effective, they need the ability to authorize services and, likewise, the responsibility for allocating services. Conceptually, though, it is clear that care coordination and utilization management are not, and should not be the same thing. In practice, they have to interact. Some have argued, for example, that care coordination functions should be organizationally separate, within the MCO, from utilization management, but have often also argued that care coordinators need to be able to influence the decisions of those doing utilization management, to make sure that they do not interfere with access to services in the treatment plan. Some recommend that the services specified in a treatment plan be automatically considered as "authorized" in advance, thus side-stepping utilization management most if not all the time. Others have argued that care coordination should have to face the discipline of limited resources, so that they target resources more precisely. They often suggest that a kind of "global budget" be available for a group of patients, and that specified kinds of care be provided (or purchased) from this single pool of resources (Zelman 1998).

View full report


"carecoor.pdf" (pdf, 439.59Kb)

Note: Documents in PDF format require the Adobe Acrobat Reader®. If you experience problems with PDF documents, please download the latest version of the Reader®