Collaboration is key to success of CM program
February 1, 2002 4 minutes read
Collaboration is key to success of CM program
Referrals come from a variety of sources
The beauty of Regence BlueCross BlueShield of Oregon’s (BCBSO) Individua program is that the case managers work closely with both employers and internal departments to make sure all eligible patients get the care they need, says Annie French, RN, manager for health care management at the Portland insurer.
The case managers get referrals from the pre-certification staff, employer groups, the customer service department, claims department, and underwriting. "What’s unique about our program is that it is totally integrated with the preauthorization department, and we receive many referrals from them," French says.
Rather than preauthorize every hospitalization or service for members, Regence BCBSO has targeted its preauthorization efforts at the services that could benefit from case management or whose treatment might be a contract exclusion, or an experimental or investigational treatment.
The process allows the case managers to let members know ahead of time if a particular treatment is not covered under their policy and to help them make decisions about their care, French says.
"We have so many ways we come in contact with and find out about patients who need help. It’s more effective to do it this way than just having contact with patients when they are discharged from the hospital," adds case manager Olivia Warfield, RN, BS, CCM.
The case management department at Regence BCBSO has educated its customer services, claims, underwriting, and marketing departments to call if they have questions about case management. "Employers, employees, brokers, and marketing people at the companies know to call their case manager if they have any issues or questions about clinical issues," French says.
In addition, the Individua case managers work with each company’s health promotion and prevention department to provide special educational programs for employees depending on what they need.
They collaborate with the employer groups’ nurse practitioner clinics to identify and treat employees with specific conditions. For instance, the care managers collaborated with the nurse practitioner at one employee clinic on an educational program for diabetics and sent a letter to all employees with diabetes instructing them to contact the nurse practitioner to receive additional education on diabetes.
Regence BCBSO’s health promotions and its prevention and disease management program intervenes with the population as a whole and manages low- to moderate-risk clients. "We work with them and provide high-end case management if the disease has progressed to the point that they need more care," French says.
Olivia Warfield, RN, BS, CCM, loves to tell employers how much money she saved them by managing the care of their members.
"I am thinking about it all the time. Aside from taking care of our people, we make sure we can save money for the employer and the patient," says Warfield, a case manager for the Portland, Oregon-based Regence BlueCross BlueShield’s (BCBSO) Individua case management program.
For instance, Warfield has saved one patient more than $100,000 a year by shopping and negotiating the price for his medicine for hemophilia.
When she was looking for a wheelchair for another patient, the first quote she got was $27,000. She asked other providers and found that she could save $6,700 on the same wheelchair.
"Even with a contract to provide equipment, it’s up to me to look around and do shopping for the patient. They don’t know where to look. And I can report to the company that I saved it more than $6,000 for one patient," she says. The case managers look hard for ways to save money for their clients. For instance, they look for the least costly level of care in which the patient can be treated.
Information on actual savings is included in regular reports to the employers that contract with Regence BCBSO for the Individua case management services. "We are really very conservative in how we report our cost savings. It’s all hard-dollar savings rather than soft dollar or conjecture. The groups really do hold your feet to the fire," says Annie French, RN, manager for health care management.
Regence BCBSO tells employers up front that signing up for the Individua program may not always save them money but has other benefits. "We set expectations at the beginning that we may not always save the employers money. We’ve been very good at telling our story and explaining the benefits of the program," French says.
The case management department reports to the employer group about how they have helped their employers. The report includes the aggregate number of times they have talked to the physician, made family contact, provided education for the family and patient, and helped the patient locate community resources.
"We provide this information in addition to the cost savings so they get some idea about what case management really does," French says.
Employers receive information about case management actions and cost saving as well as general utilization data.
Because of Regence BCBSO’s efforts to meet requirements under the Health Insurance Portability and Accountability Act, the company does not provide any individualized information to the employers. The company works with underwriting to examine claims data for specific periods of time and provides regular reports to the employers. Among the information are the top 10 diagnostic categories of employees and the percent of generic drugs being used by their particular employee group.
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