Rehabilitation, case management, and functional outcome: An insurance industry perspective1

Abstract

Case management of claims by or for an insurer, whether it be a large employer that self-insures its benefits plan or an insurance company, evolved in response to employers' desire for help in controlling escalating costs. In tracking savings for the disability and health case management services it provides to claimants, Northwestern National Life has documented significant savings. Our recent study of 9747 incurred long-term disability claims from January 1987 to December 1993 revealed an average savings of $35 in disability reserves for every dollar spent on rehabilitation services. For health claims, estimated savings produced by NWNL's medical case management program have grown from about $500000 in 1987, the program's first year of operation, to $8.1 million in 1993. From an insurance industry perspective, both health care and disability case management services maintain a strong focus on positive rehabilitation outcomes as well as cost effectiveness. Case managers evaluate rehabilitation plans based on their ability to offer quality care, interdisciplinary cooperation, and promote recovery or returning to a productive work life. The health insurance case manager gets involved in cases where there are alternative service delivery options for the treatment plan. Working closely with the physician, patient, family members and other health care professionals, the case manager looks for highly effective, outcome-based rehabilitation facilities. As treatment goals to improve health and physical functioning are reached, the focus of case management shifts to returning an individual to a productive work life where possible or appropriate. The rehabilitation case manager evaluates return-to-work potential, with a primary goal of getting disabled workers back to the same job.