Next Generation Care Management’ cuts costs, increases satisfaction
Savings per catastrophic case increased by 300%
Using a comprehensive approach to care management called "Next Generation Care Management," BlueCross BlueShield of Tennessee has cut both the number of catastrophic case managers and the average caseload while increasing the savings per catastrophic case by 300%.
At the same time, staff turnover has dropped by 10%, member and provider satisfaction have improved, and the company predicts it has saved millions of dollars by increasing patient compliance with treatment protocols.
Next Generation Care Management uses predictive modeling to stratify members into risk levels and triage interventions to the appropriate level of care — lifestyle and health counseling; care coordination; and catastrophic case management.
The predictive modeling tool embedded in MCSource, a decision-support system from Baltimore-based VIPS Inc., has enabled the health plan to use predictive modeling for the care management processes. The predictive modeling includes ICD-9 codes, members’ ages and genders, and cost of medical care and pharmaceuticals, and stratifies members into five categories, based on the predicted cost of future health care.
The predictive model allows the health plan to look at projected costs for members in the future and intervene earlier, saving health care costs and improving members’ quality of life.
Instead of waiting for claims to identify members who might be eligible for care management, the process starts when the utilization review nurse receives a call to pre-certify a patient’s medical care.
"We want to be more proactive than just taking members from a list and putting them in care management. This unique approach is much more effective than just identifying members after the claims come in, when we may have lost the opportunity to impact their care," says Sylvia Sherrill, RN, MS, director of health care services operations.
The pre-certification nurses examine the members’ predicted cost of care, factor in any additional conditions or illnesses, and refer members who may be eligible for care management to the care management triage team, where they are placed in the appropriate level of care.
Risk Level 1-2 includes members whose health care cost in Year 2 is predicted to be between $1,000 and $5,000. These receive lifestyle and health counseling, including material by mail and referrals to Internet and telephonic resources.
Risk Level 3-4 includes members whose health care costs are predicted to total from $5,000 to $25,000 in Year 2. These members are referred to one of six care coordination programs in which nurses assess and monitor their conditions and provide telephonic care coordination.
Risk Level 5 includes members whose health care costs in Year 2 are estimated to be greater than $25,000. They are referred to catastrophic case management for intensive case management in a program that has been accredited by URAC.
Before the health plan began its Next Generation Care Management Program in April 2003, the company offered only catastrophic case management to members who were referred through a trigger list and reports of cases with high costs.
"The program was effective for members with a catastrophic illness but was not appropriate for those members who would benefit simply from education, information, and lifestyle counseling," says Soyal Momin, MS, MBA, manager of research development and consulting for the Chattanooga, TN-based health plan.
Before the predictive modeling program was begun, many patients were being referred for case management when case management interventions wouldn’t have any impact on their care. For instance, people in motor vehicle accidents were on the trigger list for case management; but if their injuries were not catastrophic, there was little the case managers could do.
Another example is patients who had a stroke, were treated in the emergency department and released, and expected to recover fully after a few physical therapy sessions.
"Our case managers were spending about half their time investigating and assessing cases when they couldn’t have any impact," Sherrill says.
With the new predictive model, the health plan was able to establish the lifestyle counseling and care coordination programs and redeploy about one-third of its catastrophic case management staff to staff them.
"We are touching so many more lives. In the past, if a member didn’t need a high intensity of care, we would just close the case. Now patients who are at low risk and medium risk are receiving interventions that we hope will help them avoid becoming high risk," Momin says.
The Next Generation Care Management initiative allows some members to be referred to case management proactively, before an episode of care, rather than after the claim has been processed, sometimes as long as three months.
"In the past, it often was too late to intervene due to the disease progression, leaving little room for improvement and missing the window of opportunity for savings," Momin says.
In addition, members who are identified by claims data because they have experienced the most costly claims in the past are not necessarily those who are likely to have high future costs, he points out.
When a physician’s office calls to pre-certify a patient’s treatment, the pre-certification nurse accesses the member’s predictive modeling score and adds to it the information he or she receives from the physician office.
"The nurses often pick up additional information that’s not in the database when they talk to the doctor," Momin says.
For instance, the predictive model would show if the member has diabetes and congestive heart failure, but it might not show depression if the claim medication for that condition hasn’t been received by the health plan.
The nurse has the capability to supplement the prediction for depression resource requirements to the model and predict the costs identified with the new condition. The predictive model predicts resource consumption for the next two years.
"If we can get the members into case management as they come through the pre-certification process, while services are being rendered, we can be very proactive," Sherrill says.
If the predictive modeling data have stratified the member as being low cost and the nurse is being asked to certify a new episode of care that is likely to be high cost, the member is referred to case management.
If the member already has been stratified as high cost and has a new episode of care, he or she also is referred to case management.
"When the pre-certification nurse adds information about the member’s new episode of care, it usually increases the stratification of the member and may change how we handle that patient," Sherrill says.
Members whose initial predictive modeling stratification and current episode of care identify them as being at risk are referred to a triage unit where the nurse pulls all the patient information together and steers them into the program they should be in.
"We are putting tools in the hands of nurses to allow them to intervene earlier and coordinate the members’ care," Sherrill says.
Members with a low score receive basic education through mailed materials.
The health plan refers members stratified as moderate to programs that can make an impact.
BlueCross BlueShield of Tennessee already has developed six care coordination programs and is working on several more in which RN case managers assess and monitor diseases and conditions and provide telephonic care coordination, working with the members and their physician. These include pharmacy care management, emergency services management, Centers of Excellence, transition of care (formerly known as discharge planning), condition-specific care coordination, and disease management.
The pharmacy care management program includes a program to ensure members with hepatitis C receive the optimum length of drug therapy; a program to encourage compliance with beta-blockers after a heart attack; a migraine care management program; and a polypharmacy care management program.
Members who frequently use the emergency department are referred to the emergency services management program and receive counseling from an RN with psychiatric training and guidance on appropriate care options.
The health plan’s Centers of Excellence program has identified physicians who provide cost-effective and quality care for members with asthma, diabetes, congestive heart failure, coronary artery disease, and chronic obstructive pulmonary disease.
The transition of care program aims to reduce the length of stay, costs for per diem admissions, and readmissions, and provide a smooth transition of care.
The insurer also provides in-house care coordination for some chronic conditions and disease management services, through LifeMasters Supported SelfCare, Inc.
Patients who stratify as high cost are referred to catastrophic case management for a detailed assessment, a care plan, and more frequent follow-up. "This is the area where interventions have the most impact on efficiency and savings," Sherrill says.
The predictive model actually has helped reduce the staff in catastrophic case management because of the reduced number of cases.
In addition, because all the cases now handled by the catastrophic case managers need intensive case management, the average savings per case manager’s caseload has gone up 300%.
"The significant number of cases that were not impactable were diluting savings. The case managers still had to make an assessment on the cases that they couldn’t impact. It cost us a great deal of money to be ineffective," Sherrill says.
Other outcomes include a hepatitis C program that has generated $1.5 million per year in medication cost avoidance among patients in the program and a $1.3 million per year cost avoidance for patients in the AMI beta-blocker program.
After two years experience of using predictive modeling for care management, the health plan is enhancing its predictive modeling capability with a Rational Artificial Intelligence (RAI) component that will help identify members who are low cost this year but can be expected to move into a higher cost bracket in the future.
The RAI index will identify gaps in care, such as lack of foot examinations for diabetics, and flag members who are beginning to show comorbidities.
"Artificial intelligence will pull together a full picture of someone who is just starting to use services that indicate his condition is likely to change," Momin says.
Using a comprehensive approach to care management called Next Generation Care Management, BlueCross BlueShield of Tennessee has cut both the number of catastrophic case managers and the average caseload while increasing the savings per catastrophic case by 300%.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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