Individual case management of chronically ill pays off for insurer
Employers contract for special case management services
Under a unique arrangement with employer groups, case managers at Regence BlueCross BlueShield of Oregon (BCBSO) in Portland provide individual case management for people with chronic or catastrophic illnesses who require long-term care, or have psychological and social needs that require coordination of or access to multiple levels of care.
Recognizing the potential benefit of a program to address the serious needs of the chronically ill, Regence BCBSO created Individua, a program that assigns case managers to each employer who purchases the Individua program.
Members who need care management services deal with the same case manager who coordinates their care throughout the continuum. The plan has received high praise from employees who have only one person to call about their health care needs, and employers, who receive regular reports on their employees in the Individua program. (For details on the reports, see "Reports include info on what case managers do," in this issue .)
"To my knowledge, we are the only insurer-based case management department that provides this type of service for specific employer groups," says Annie French, RN, case manager and manager for health care management. The case management program currently serves 32 employers with more than 200,000 members. Regence BCBSO’s Individua program has 37 case managers who deal with 40-60 acute interventions at a time.
"We can have up to 100 or more cases because some are in the monitoring phase, where we watch the claims and evaluate what is happening with the care," French says.
The company has specialty case management programs that work only with certain types of cases. For instance, two case managers deal only with transplant patients, French says.
The case managers provide individual care management for members at the employee group to which they are assigned. "In a world where people so often feel like a number, Individua focuses on the individual’s needs," French says. Having in-house case management for patients who need it is particularly effective for an insurer because the case managers have access to all aspects of information regarding the members, French points out.
"Our program sets us apart from independent case managers because we know the provider contracts, the member contracts, what the employer has purchased. We get the clinical picture, make contact with the members, and learn their psychological and social needs. Because we have access to all their claims information, we are able to take a look at all the information that is available," French says.
The case managers often follow the patients from the time they are born. For instance, Olivia Warfield, RN, BS, CCM, is managing the care of one child who is autistic, another who has cerebral palsy, and another who has a genetic disorder.
"It really is a wonderful way to stay involved with a patient. When you work with them just in the hospital, you never know what happens after discharge," Warfield says. She’s worked for years with one patient who has major physical defects and has needed a variety of adaptive equipment.
"I worked with the mother for many years, and in May the grandmother called to say the mother had died, so I moved on to the next generation of caregivers. It made me feel better to know that the family was aware of how I can help," Warfield says. When a patient is not healing, the care manager consults with a team in suggesting treatment for the patient. If the patient’s primary care physician accepts the plan for additional treatment, the case manager guides the patient through an alternative treatment plan.
Often the case managers go far beyond meeting just the medical needs of the patients. For instance, Warfield worked with an elderly patient who was very sick and had no family in Oregon. She was able to help the patient’s sisters in California find local resources to help care for the patient after she was discharged from the skilled nursing facility.
Another patient, with cancer, an immune deficiency disorder, and hemophilia, couldn’t afford to pay for his medications at the time of purchase and wait to be reimbursed. Warfield stepped in and made special arrangements with the pharmacy to save out-of-pocket expenses for the patient.
Regence BCBSO started its case management program in 1984, working with a single employer group with about 3,500 employees to help patients navigate the health care system.
Early on, the program focused on patients in skilled nursing facilities, inpatient rehabilitation, or those who required multiple layers of care, such as home health. "We knew that there were some patients who needed more help than we were giving with just preauthorization. The single-employer-specific case management program was the foundation for the program we have today," French says.
In 1991, the company began marketing to employer groups with more than 200 employees. When employers purchase the program, the company dedicates case management staff specifically to their employees, depending on the size of the company and the members’ needs. For instance, only one case manager is assigned to smaller groups. Larger groups may have as many as three case managers servicing them.
The case managers also act as benefit managers to help the patients find the best options for them. For instance, a person is qualified for a skilled level of care in a nursing home, but the family prefers to keep him or her at home. The patient doesn’t have benefits for hourly skilled care, so the case managers take what the company would have been paid on skilled nursing facilities benefits and convert it to money that will pay for care at home.
"Our responsibility is to help families come up with plans of care for their loved ones. We work with the family as well as the patients," Warfield says. The Individua case managers also manage care for a high-risk pool of patients who are denied insurance because of their medical conditions. The Oregon Attorney General’s office coordinates a program in which a group of insurance companies underwrites care for these patients.
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