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Thought Leaders


Reduce spending

with care management

Business-process management software enables the automation of goal-directed processes
across people and systems, and continuously monitors patient events.

By Elizabeth Hart
oday, cost concerns are greater than ever. With due to his chronic heart condition, but since that is a dif-
ferent group using different systems, the nurse handling
his hospitalization has no way of easily accessing critical
the rise of consumerism, individuals also are
becoming more involved in their own health-
care decisions. Both patients and physicians data, such as recent healthcare assessments that could
alike are viewing health plans more as allies and also as be pertinent to the situation at hand.
important sources of critically needed healthcare data. When the case manager needs to authorize a new
Fortunately, technology has changed, and the industry service for the hospitalized patient, she needs to submit
now has the tools it needs to quickly deploy new cost- an internal request to the plan’s utilization department,
cutting approaches and broaden its role as “health and which could involve rekeying of data already captured in
wellness” facilitators. In addition, many health plans have the previous two systems. This structure is ineffi cient,
already been using this technology to gain administra- slow and prone to manual error.
tive effi ciencies. Now, plans need to turn that power to Business-process management (BPM) enables the
clinical activities. automation of goal-directed processes across people
and systems. It can link the multiple legacy systems
Health plans using BPM technology
currently in place for each of the care-management ar-
eas and drive whole-person care for individual patients,
for care management have made
while simultaneously managing targeted programs for
impressive achievements.
larger population groups. The technology continuously

monitors patient events, looking through authorizations,
Plans report reaching 100 percent accuracy in claims, pharmacy data and more, and generates real-time

their authorization processing,
alerts to care managers when it discovers alarming activity
or behavior outside the norm.

55 percent reduction in the cost per case,
The system guides users through processes, and

with a similar drop in case-handling time.
presents relevant data intelligently when needed or
requested, including a comprehensive view across the

patient’s activities and information, created from data
Care-management activities at health plans, including pulled from the plan’s multiple systems and documents.
utilization, case and disease management, traditionally In this way, the technology ensures that plans are consis-
operate in organizational stovepipes that use disparate, tently administering the highest-quality care programs
technologically immature systems. Several functions and that the programs are being continuously tailored to
are still manual, requiring operators to toggle between individual patients.
systems and search through spreadsheets to fi nd the BPM systems also automate menial tasks such as send-
Nelson Publishing
rules necessary to make appropriate clinical decisions. ing correspondence and wellness materials, providing
Often, health plans have outsourced some of their care- multichannel notifi cations to wide-spread patient-sup-
2500 Tamiami Tr N
management functions to external organizations, which port networks, updating case fi les and keeping systems
Nokomis, FL 34275
further exacerbates the problems of missing integration synchronized.
and inadequate coordination. Health plans using BPM technology for care manage-
For example, an unconscious, 40-year old man rushed ment have made impressive achievements. Plans report
to the hospital after being in a car accident would be man- reaching 100 percent accuracy in their authorization pro-
aged by a nurse using a plan’s case-management system. cessing, 55 percent reduction in the cost per case, with
He may be well known to the plan’s disease managers a similar drop in case-handling time. User training has
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