Proactive case management pays off for insurer in outcomes, cost savings
Program achieves a minimum 4.5-to-1 return on investment
The pilot project for Anthem Blue Cross and Blue Shield’s proactive case management program was so successful that the insurer has expanded it to include 16,000 members who will receive intensive, personalized interventions to help them manage their chronic diseases.
The pilot program started with an intervention group of 1,200 members who were the beneficiaries of the new proactive approach to case management and a control group, subject to Anthem’s traditional case manager services, such as authorization of treatment, coordination of care, and discharge planning.
"We focused on authorizing coverage and services, but there was nobody there to really look at the bigger picture," says Alena M. Baquet-Simpson, MD, medical director, state of Ohio, Anthem Club Cross and Blue Shield Midwest.
Members in the intervention group went through a thorough assessment, worked with their case managers, or care counselors as Anthem calls them, to set goals and to come up with ways to meet them. Their care coordinators call them at regular intervals to check on their progress and answer questions.
In the first nine months of the pilot program, members receiving the proactive case management interventions had 11% lower inpatient admission rates than the control group, plus their inpatient costs were 10% lower. Total cost of care for the intervention group was 13% lower than those of the control group.
When the actuaries looked at expenses vs. cost savings, they calculated that the project had between a 4.5-to-1 and a 5.2-to-1 return on investment.
"One of our goals in the pilot study was to determine the value of the proactive approach to members. We put a lot of effort into designing the program so the results would be valid. Our actuaries evaluated the outcomes and put them to the most stringent level of analysis," Baquet-Simpson says.
Clinical outcomes, based on member self-reported data before and after the program began, included:
- 13% fewer members were smoking.
- 19% more were following low-fat or low-cholesterol diets.
- 16% more were participating in a regular exercise program.
Among members in the program with coronary artery disease, an additional 13% were able to reduce their cholesterol level to below 200.
Among members with congestive heart failure, there was a 33% increase in people weighing themselves daily.
Diabetics improved in five critical areas: receiving dilated retinal exams, foot exams, cholesterol screening, hemoglobin A1C testing, and glucose control testing. In a member satisfaction survey, 97% of members rated their overall satisfaction with the program as good, very good, or excellent.
When asked how satisfied they were with the support and tools provided by Anthem Blue Cross and Blue Shield to help them manage their own health, 98% were satisfied.
"We found out it is possible to achieve a win-win situation. Our members are winning because of improved health. The physicians are winning because we are promoting better adherence, and the health plan wins because of enhanced member satisfaction and optimized resource consumption," Baquet-Simpson says.
The program is geared toward chronically ill people who are likely to need health care services.
"The care counselor program is more proactive, member-centric, and collaborative than the traditional case management program. It’s all about empowering members to make health changes. The care counselor works in a supportive role, helping the members identify what motivates them toward making healthy changes that will reduce the need for services in the future," says Mary Beth Newman, RN, CMAC, A-CCC, senior project manager — case management at Anthem BCBS Midwest in Mason, OH.
Members are encouraged to call the care counselors with questions or if they have information they want to share.
Physician responsive has been positive.
"We let the physicians know that we are here to help them and to support adherence to their treatment plan," Newman says.
The care counselors are licensed health care professionals with significant clinical experience. Anthem Blue Cross and Blue Shield provided training in case management, chronic diseases, and in how to determine a member’s willingness to change.
The care counselors work with members who have been identified as having the potential for high resource utilization. They determine what the members’ needs are, help them set goals, and facilitate addressing their needs and goals.
"The key functions are defined by case management standards of practice. They are assessors, planners, facilitators, and advocates," Newman says.
Identifying the member’s personal goals and developing a case management plan to support them is a key to the program, she adds.
For example, the client of one care counselor had diabetes, coronary artery disease, and hypertension and weighed 350 pounds. Every clinician the man had come in contact with had told him to lose weight, but that wasn’t his goal.
Once the care counselor established a rapport with the member, she found out that he didn’t like taking so many medications and wanted to get off some of them.
"As a natural fallout, he realized by himself that losing weight was the way to cut down on the medications he had to take," Newman says.
As a result, the man lost 50 pounds.
"After he lost the weight, he was able to get off his diabetes medicine and avoid the side effects it caused. His blood sugars and hemoglobin A1C are normal now. He lost the weight because the care counselor worked with him to meet his personal goal rather than setting her own goal for him," Newman says.
The underlying focus of the program is for the care counselor to work with members to educate and empower them to manage their own health, Baquet-Simpson says.
The members are more likely to meet personal goals than those set by the care counselor, she adds.
"The care counselors share educational materials with members. The educational materials and clinical focus are all on evidence-based care. Focusing on methods that have been proven to enhance health are very important when it comes to making sure the results are what you are looking for," Baquet-Simpson says.
Care counselors are assigned by geographic areas to ensure that they are familiar with the community and what resources are available for members.
"It’s a big asset when it comes to helping members navigate the system and coordinating needs with benefits and resources," she says.
The care counselors typically manage the care for about 150 members, depending on the severity of their illness and the care they will need.
The care counselors’ assessments categorize the members into risk levels, each with a minimum number of interventions.
"We set a minimum number as a safety net so no one will fall through the cracks. The low-risk members are contacted at least quarterly," Baquet-Simpson says.
The care counselors can graduate members from the program based on their progress or lack of it.
"When we went into it, we didn’t have an endpoint. We learned that there are some people who meet their goals and others who reach a plateau as far as their readiness to change," she adds.
The biggest reason that members are graduated from the program is that they have met their goals.
"The care counselors are engaged in regular monitoring and evaluations and know when the goals have been met," Baquet-Simpson reports.
The care counselors graduate some members when they reach a plateau or haven’t made any progress despite interventions.
"The care counselors continuously assess readiness to change, and if they don’t see that the member is moving toward change, they think about graduating them from the program," Baquet-Simpson says.
If a member starts to show high-risk characteristics again after graduating from the program, the predictive model identifies them, their care counselor is alerted, and the member is re-enrolled.
The pilot project for Anthem Blue Cross and Blue Shields proactive case management program was so successful that the insurer has expanded it to include 16,000 members who will receive intensive, personalized interventions to help them manage their chronic diseases.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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