Care management software is the system a health plan uses to look after its members with complex illnesses, such as cancer or heart failure, and to set the agreed treatment paths that decide what the plan pays for. A care manager is usually a nurse or social worker employed by the plan. She stays in touch with a member between doctor visits. This software is sold mainly to health plans in the United States. Some of it is built by companies with engineers in Pune.
Why does a health plan pay for this? A small share of members causes a large share of the plan's costs. Many of these costs come from avoidable events: a missed medicine, an emergency visit, or a return to hospital soon after discharge. A care manager who calls at the right time can prevent some of them. That is better for the member, and it costs the plan less.
The software does three jobs. First, it finds the members who need help. It reads claims and records from a healthcare data platform, and it ranks members by how likely they are to fall ill soon. Deciding who needs attention first is a form of triage. Second, it gives each care manager a list of members, with a care plan, tasks and notes for each one. Third, it holds clinical pathways. A clinical pathway is an agreed treatment plan for one condition, based on medical evidence. It decides which treatments the plan approves quickly.
Imagine a member of a health plan in Kansas City, Missouri, in the United States, who has just been diagnosed with breast cancer. Her oncologist asks the plan to approve a course of chemotherapy, through prior authorisation. The software compares the request with the plan's pathway for her type and stage of cancer. The treatment matches the pathway, so it is approved the same day. If the doctor had asked for a treatment outside the pathway, an oncologist employed by the plan would have reviewed the case instead. The software also assigns her a care manager. The care manager calls her before the first session, and she arranges transport to the hospital and a dietitian's advice.
Care management connects to the claims systems. The plan's health plan administration system records the care plan, and claims adjudication pays the treatments that were approved. Care management also links to what members do at home, such as digital diabetes management or virtual nutrition counselling.
Care management is different from the hospital's own care. The member's doctors decide her treatment. The health plan decides which treatments it pays for, and its care manager helps the member through them, across all her doctors.