Project to demonstrate value of proactive CM
Members pleased with the process
While Anthem Blue Cross and Blue Shield is shifting its case management efforts from a traditional benefits model to a proactive model that empowers patients to take control of their own health, management wanted to demonstrate the value of the change.
As a result, a multidisciplinary team has designed and begun a pilot project to track and evaluate the effectiveness of interventions with members with eight conditions that typically consume a large amount of health care resources.
"Anthem considers proactive case management to be a cornerstone of the company’s approach to member care. We feel this approach offers a great opportunity to create a win-win situation for members, providers, and for Anthem. Because this is a new area, we started by putting an intense effort into developing a pilot project to demonstrate its value, says Alena M. Baquet-Simpson, MD, medical director, state of Ohio, Anthem Blue Cross and Blue Shield (BCBS) Midwest.
Anthem Blue Cross and Blue Shield, with headquarters in Indianapolis, covers about 8 million members in Indiana, Kentucky, Ohio, Connecticut, New Hampshire, Maine, Colorado, and Nevada.
About 500 members enrolled in the pilot project during its first six months. They are diagnosed with eight key conditions: coronary artery disease, congestive heart failure, diabetes, hyperlipidemia, hypertension, stroke, chronic renal failure, and chronic obstructive pulmonary disease.
When they examined their member data before beginning the project, the management staff at Anthem discovered what they had known all along — that a small group of members consume a large amount of health care resources.
In fact, in a sample of the commercial population studied in the year 2000, 7% of members accounted for more than 50% of the claims paid.
"The problem we’re trying to address is that small subgroup that utilizes a disproportionate share of health care resources. There is an opportunity to work with members and provide a pro-active approach with the results of improved member health and lower resource consumption," Baquet-Simpson says.
The company started the transition to member-centered case management in early 2001. The pilot project design team spent about nine months planning the project before enrolling the first members in October 2001.
"We were looking to increase the amount of direct member contact. We wanted to educate the members and empower them to take a more active role in health care," says Mary Beth Newman, MSN, BC, A-CCC, senior project manager — case management at Anthem BCBS Midwest in Mason, OH.
The organization wanted to collaborate with members and their physicians to identify problems or issues earlier and to coordinate and optimize benefits.
"In the traditional model, we took a more reactive approach, geared toward cost containment. We focused on the people in acute care and had minimal physician or member contact. Our activities were primarily arranging, authorizing, and approving," Newman says.
In the proactive model, the member is the focus.
"Rather than focusing on cost containment, we focus on quality and outcomes. We are looking at chronic care conditions and the needs of the whole person. Activities include assessing, planning, coordinating, monitoring, and evaluating," Newman adds.
The organization recently has compiled data from the first six months of the pilot program and is studying them to develop the outcomes data.
In the meantime, a lot of anecdotal data show that the members are pleased with the process, Baquet-Simpson says.
One member described the case manager’s role as "like having an experienced guide in a foreign land."
Other members have commented that they like the idea of having one case manager who follows them instead of dealing with a different person every time they contact the insurer.
"The members like being empowered to take a more active role in their own care and appreciate the help we give them in navigating the health care system," Baquet-Simpson says.
It’s a winning situation for members because it will result in better health outcomes. The providers appreciate it because the insurer is working with their patients to reinforce and increase compliance with treatment plans.
"For Anthem BCBS, we need to be able to provide answers to hard questions, such as what values does proactive case management bring, and does the investment really make sense? We expect that the pilot will answer those questions," Baquet-Simpson says.
The company is conducting the pilot project among its commercial products rather than the Medicare and traditional indemnity products.
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