Plan fine-tunes its CM via pilot program
Staffing changes, comorbidities are focus
When the leadership team at Anthem Blue Cross and Blue Shield discussed its future medical management strategy in 2001, the team considered that proactive case management would be a major component.
At the time, there were little data to demonstrate that intensive case management added value, says Alena M. Baquet-Simpson, MD, medical director, state of Ohio, Anthem Club Cross and Blue Shield Midwest.
"We wanted to develop a program to decide what would work for our organization in terms of case management goals and the daily work of case managers. We structured a pilot program so we could have valid outcomes to demonstrate the impact of the interventions," she says.
Anthem Blue Cross and Blue Shield provides health care benefits to more than 11.7 million people in nine states.
An examination of the cost data showed that 7% of the commercial population was responsible for 50% of the claims costs over a 12-month period. The goal of the pilot project was to create a win-win situation for the members and the health plan through a proactive case management approach.
"We wanted to assist them in improving their own health and optimize resource consumption at the same time," Baquet-Simpson says.
The health plan developed a predictive model to identify members for both the control and the intervention group. The members had similar characteristics, such as chronic conditions and intervention patterns.
The control group received traditional case management interventions, such as approving coverage for treatment and discharge planning. The intervention group received intensive, proactive case management.
After studying the data for the first nine months of the pilot project, Baquet-Simpson and her team at Anthem Blue Cross and Blue Shield made changes in the proactive case management program, based on lessons they learned.
"The results of our pilot project were extremely positive and suggest that proactive case management can have a positive impact. Along the way, we have learned some valuable lessons that have allowed us to change our program to make it even more effective," says Baquet-Simpson.
She shares some of the lessons with Case Management Advisor:
• Take into account whether a member is ready to change.
"We’ve learned by experience how critical it is to take into account an individual’s readiness to change," Baquet-Simpson reports.
The company brought in outside consultants to educate the care counselors on how to determine a member’s willingness to change. The case managers earned continuing education credits for participating in the educational process, which included role-playing and videos along with didactic lessons.
"We realized along the way how critical it was to focus on readiness to change and confidence to change and to give the care counselors the tools to assess them. Part of the role of being an advocate is respecting the member, and you get to the point that you have to respect their feelings about changing," she adds.
• Focus on comorbidities.
In the beginning, Anthem’s proactive case management program focused on eight chronic conditions that typically consume large amount of health care resources. They are: coronary artery disease, congestive heart failure, diabetes, hypertension, hyperlipidemia, stroke, chronic renal failure, and chronic obstructive pulmonary disease.
After a while, the team realized that other conditions, particularly obesity and depression, affected the health of the members in the program.
When Anthem evaluated one group of members, it found that 81% had issues relating to obesity management or overweight and that 43% had problems with depression.
"One big lesson we learned what that we needed to consider other comorbid conditions," Baquet-Simpson says.
The program now includes counseling for depression and obesity information along with the education on the members’ chronic illnesses.
• Free up the RNs to focus on members’ health behaviors.
The pilot project pointed up the importance of having someone besides the case managers handling clerical and administrative tasks, Baquet-Simpson says.
As part of the expansion program, the health plan has hired people who are not registered nurses to handle the enrollment process, calling the members to explain the program and setting up the first telephone appointment with the care counselor.
"Care counselors in the proactive case management program are able to spend more time intervening with members. We needed to free them up from clerical tasks to concentrate on direct member contact," she says.
• Develop a comprehensive medical management system.
The success of the program has allowed the insurance plan to update its medical management system to support the proactive case management program on a long-term and systemwide basis.
"We want to have as much of the process automated as possible to maximize the case managers’ time. With the success of the program, we’ve gotten approval to do so," Baquet-Simpson adds.
When the leadership team at Anthem Blue Cross and Blue Shield discussed its future medical management strategy in 2001, the team considered that proactive case management would be a major component.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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