Enabling conflict-free case management

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Frank Spinelli
Frank Spinelli
As our population ages and the number of people with disabilities increases, the demand for long-term services and support will surge. Meeting this demand requires a continuum of LTSS, and one of the most important of these services is conflict-free and person-centered case management. Case management can include an array of actions, but one of the most important involves performing assessments and identifying a participant's needs and strengths.

With the growth of LTSS programs, a number of providers also have expanded their operations to include case management. However, having case managers and service providers in the same organization can increase the risk for conflicts of interest. An assessor employed by a provider has an incentive to recommend more expensive care options, or, in some cases, not recommend what a person needs. The Centers for Medicare & Medicaid Services recognizes the potential for conflicts of interest and recommends three ways for states to prevent them:T

  • The state retains control of the assessment.
  • The state contracts with an outside independent entity that does not have any financial interest in the amount or type of long-term services the person chooses.
  • The state allows assessment and services to coexist in one organization if the organization establishes firewalls separating the two units.

The trend to move more LTSS participants to managed care plans is fueling the debate. Most of these plans are taking on risk and have some financial interest in the outcomes. Many plans are attracted to the firewall approach because it requires the least change. 

But will interior firewalls eliminate conflicts of interest? And will participants trust them?

There may be disagreement over the best approach, but an independent assessment performed by an impartial outside entity can provide the most neutral recommendation for dealing with this complex situation. Independent assessments are unbiased. They provide participants and their families with a detailed account of the participant's needs, strengths and short- and long-term goals. Such a report can offer a solid foundation for measuring a provider or plans' performance. It helps reduce worry that care decisions might be driven by factors unrelated to the participant's well-being.

This is also a best practice from other industries. When financial institutions need an audit, they hire an outside CPA. If someone needing surgery wants a second opinion, they go to a doctor not affiliated with the surgeon. Why wouldn't we want the same for our seniors and individuals with disabilities who are seeking services and support? 

Some states are already opting for eligibility assessments by independent entities. This is a good first step, but it can go further. Programs should provide participants and their families with solid recommendations for needs, goals and options – not just a stamp that says, “You are eligible for services.”

The long-term care system today needs to empower and enable more social and active lives for its participants. Caring for them can be an opportunity to improve their lives. Providing independent assessments is a crucial step in this journey.

Frank Spinelli is the vice president of Long-Term Care Solutions at Xerox.


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