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Defining the parameters of case management in a managed care setting
1URAC/American Accreditation Healthcare Commission, Washington, D.C., USA.
Managed Care Quarterly
|March 17, 2001
Summary
Case management evolved from utilization review to improve flexibility. This study examines its diverse regulations and lack of definition, proposing mechanisms for a universal health benefits case management definition.
Area of Science:
- Healthcare Administration
- Health Policy Analysis
- Case Management Evolution
Background:
- Basic utilization review lacked flexibility, prompting the evolution of case management.
- Current case management faces challenges due to diverse state regulatory oversight.
- A clear, universal definition for case management is currently lacking.
Purpose of the Study:
- To explore the evolution of case management from utilization review.
- To examine the regulatory landscape and definitional ambiguity of case management.
- To propose mechanisms for establishing a universal definition of case management within health benefits plans.
Main Methods:
- Literature review on the historical development of case management.
- Analysis of state-level regulatory frameworks governing case management.
- Conceptual framework development for defining case management.
Main Results:
- Case management emerged as a more flexible alternative to basic utilization review.
- Significant variation exists in state regulatory oversight of case management.
- A lack of a precise, universally accepted definition hinders consistent application.
Conclusions:
- A universal definition is needed to standardize case management practices in health benefits.
- Proposed mechanisms offer a pathway toward achieving definitional clarity.
- Addressing regulatory diversity and definitional gaps is crucial for effective health benefits case management.