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HMSA case managers are patient advocates, not UMs
System promotes collaboration, not competition
Case managers with the Hawaii Medical Service Association (HMSA), a nonprofit medical indemnity association, follow a practice model that differs significantly from that used at most other insurance companies, says Melissa Bojorquez, ACBSW, MBA, CCM, supervisor for the HMSA case management program.
That difference may have something to do with why HMSA — the independent licensee for Blue Cross Blue Shield for the state — was chosen to receive the March of Dimes Franklin Delano Roosevelt Award for Distinguished Community Services. A video, Circle of Healing, which was made in connection with the award, depicts HMSA’s handling of four different cases in which its members were faced with devastating illness.
"In some settings, case managers are also utilization managers," Bojorquez notes, "but it’s difficult to represent the patient if you’re playing that role. In our model, we don’t place case managers in that position. Our case managers aren’t necessarily the decision makers, but rather the facilitators."
Case managers serve as patient advocates, she explains, working toward the best possible plan of care. Decisions on whether to cover a particular treatment are made by the HMSA medical director, Bojorquez adds.
"Sometimes our case managers have to deliver not-so-good news," she says, "but we try to move beyond what’s not payable to, How can we access the care we need for the patient? Do we need to transition to another community funding source, another program?’ It’s important for us to say to the patient, Here is the outcome, and I know it isn’t what you expected, but can we move forward?’"
Through such efforts, she notes, "our organization has played an important role in making health care affordable from a member and an employer group perspective."
Another advantage of having health plan case managers, Bojorquez points out, is that they can follow members from multiple locations. "They can follow a member from the hospital to a rehab facility to home care to independent living or assisted living," she adds, "an advantage that case managers in specific facilities or settings do not have."
One of the cases cited in the March of Dimes award involved an infant who was born with a nonfunctioning bowel and ultimately had to be sent to a West Coast facility for a small bowel transplant, Bojorquez says.
"That took a lot of coordination, with a member going out of state who had to be supported in an unfamiliar area," she says. "The case manager was there to support the family throughout the process."
The case manager worked with utilization management to preauthorize the treatment, which involved determining that the facility was a "Blue Quality Center for Transplant" under the Blue Cross Blue Shield "center of excellence’’ requirement, Bojorquez adds. "There was a lot more coordination and research than with organs like livers or hearts that are more commonly transplanted."
In addition to being a conduit of information for issues within HMSA, she says, the case manager worked with outside payer sources to seek coverage under other programs for which the child might be qualified. For example, it costs between $35,000 and $50,000 to transport a critically ill patient from Hawaii to the mainland, Bojorquez explains. In this case, that expense was covered by another agency.
That child’s care is ongoing, with trips back and forth between facilities in Hawaii and California, she says. "The family is very appreciative of the case manager. They think of her as a friend, someone to call for advice."
What makes Hawaii unique
One of the factors that makes Hawaii’s health care environment unique, Bojorquez explains, is that the state’s Prepaid Health Care Act requires employers to provide insurance to any person working 20 hours or more per week, she adds.
Because of that requirement, it is not uncommon for case managers to have to coordinate care and services that have coverage by several insurers, Bojorquez says. When a case involves coverage by more than one health plan, she adds, the coordination of benefits can be complicated.
The unique nature of the HMSA model allows case managers to take a cooperative approach when it is necessary to navigate between two plans, she points out.
"It might be two competitors — HMSA and Kaiser, for example — working together, but the issue is how best to coordinate the patient’s care, not to try to avoid being the one to pay for the care."
In many cases, Bojorquez notes, "[the other insurer] covers part of the care, and we cover part of it." Because of the universal nature of coverage in Hawaii, she adds, "there is no need to be adversarial. We can work collaboratively."
With about 60% of the market and 670,000 members out of a population of nearly 1.3 million, HMSA is the largest insurer in the state, she says. "Kaiser is next, and union plans or third-party administrators have the rest."
HMSA has been part of the Blue Shield Association since 1946, and since 1990, has been the independent Blue Cross Blue Shield plan for the state of Hawaii, Bojorquez explains. The case management program has been in place since 1988, she notes, sparked in part by needs associated with the AIDS epidemic.
With advances in medical technology that support home care of the complex medical patient, she says, "there needed to be a unit that assisted members with these types of catastrophic treatments. We needed a program to review the appropriateness of home services that were in lieu of being in the hospital."
In seeking to fill those needs, the HMSA program evolved from individual benefit management to a more focused care management model, adds Bojorquez, "always with the intent of helping members with complex care needs."
HMSA was founded in 1938 as what is known as a mutual benefit society, she explains. "It was started by social workers, teachers, and nurses because of the need for affordable health care in the community. We now have different types of benefits, but a lot of our role is navigating members on how best to use their benefits."
Members pay dues to the nonprofit organization, Bojorquez explains, and it is managed by a 27-member community board that serves without compensation. "Insurance is the primary product, but there is a range of other programs for which HMSA has been the catalyst. We still have the mission of bringing quality, affordable health care into Hawaii."
Among other services, HMSA provides disease management, preventive health, health education, and screening programs, she notes. In some instances, Bojorquez says, the organization’s role is bringing in or helping providers to develop services that aren’t in the community, and establishing a reimbursement model.
Nurses were the basis of the case management program when it started, she points out, but the agency progressed to a nurse/social service or care coordination model. "That was because a lot of the need was not always for treatment of the disease but for the coordination of resources and services."
What happens today
Now the case management program refers to and coordinates with HMSA’s disease management program for the education and management of chronic health conditions, she says, as the HMSA case management staff focuses on members with serious and/or chronic long-term illness, those with complex placement/social needs, and children or elderly patients who are medically fragile, among others.
"We are addressing the needs of the patients, but we are also putting a lot of effort into assisting the families, because they are the caregivers," Bojorquez adds. "We look at what is needed to help maintain the patient at home. Another program might be more concerned with clinical aspects, compliance with protocols. We look beyond that."
Palliative care, education of advance directives, and transition to hospice care are among the program services, she notes. "Our highest volume is oncology, and we have a lot of patients who are at the end stages of disease or who are suffering from life-limiting disease.
Once the patient is taken care of by the appropriate providers, the issue is, How do you support the family? Are they at risk of breakdown? Do they need respite care?’"
In addition to Bojorquez, the case management staff includes Linda Dullin, RN, senior case manager, and four social work case managers, she says, as well as the medical director.
Dullin performs the first level of clinical review for all referrals. The referrals, which come by telephone, fax, or e-mail, are fielded by an HMSA intake specialist, who takes the information on the referral, checks eligibility, puts the appropriate medical and plan/benefit documents together, and sends them to Dullin.
Most referrals come from within the organization, Dullin says, whether from a member, a member’s family, or another facet of HMSA, such as the disease management program. Physicians account for the smallest volume of referrals, she adds, but HMSA hopes those numbers will increase.
"Usually, our members have far more contact with a physician than with HMSA, and the physician is aware when someone has a particular need," she notes. "Who better to get that information from than somebody who’s right in the thick of it?"
Physicians sometimes think of case management as being utilization management, Bojorquez says, and because they fear case managers will take an adversarial approach, they are reluctant to seek their help. "They shouldn’t be," she adds. "We want to be an adjunct to their care of the patient."
The program would welcome more referrals from hospitals that are providing care to HMSA members, Dullin notes.
"Case management technically is a benefit, but most members don’t realize that," she points out. "We might be able to say, This person has skilled nursing benefits. Rather than discharging the patient to a home that may be unsafe, why don’t we send him to short-term rehabilitation facility so he can get stronger and have physical therapy?’ A lot of times that was never thought of."
Once a referral comes in, Dullin explains, she reviews the material available, and if she can’t make a determination, requests additional information. "If it’s, say, a premature infant, with potential special-needs coordination, I will ask the hospital to send admission history and physical and consultation notes."
If a physician is making the referral, and Dullin has the information on the recent hospital stay but knows there were pertinent care events before that, she will contact previous providers.
"Because we’re part of an insurance company, we don’t run into as much difficulty with HIPAA [the Health Insurance Portability and Accountability Act] privacy requirements as some might think. When a person is admitted, part of the [privacy notice that is signed] allows release of their information."
Interestingly, she often has to "remind the provider that we are the insurance company," Dullin says. "I don’t hesitate to put the request in writing, just to reassure the provider. We also send a copy to the member, because one of the things you’re supposed to be able to do under HIPAA is go to the insurance company and find out to whom your medical information is being released."
After looking at the clinical implications of the additional information she has requested, Dullin says, she sometimes still needs to talk with the member or his or her family to determine, for example, if there is home care of any kind or a private caregiver.
"If we’re talking about getting community resources, I want to find out what they already have in place," she says. "We want to empower them as much as possible.
"Our case management is to help them navigate and coordinate and maximize benefits, but we also work with them on what they want to accomplish," Dullin points out. "Unless we ask what they want and they tell us, the goals become our goals and not those of the members."
When she completes her evaluation of the case and determines that the person is appropriate for case management, Dullin gives the assignment to one of the social work case managers, she says.
Rather than just handing over a file, Dullin adds, "I try to give the case manager an overview of the case. All the information is in the hard copy, but I give them a highlight, something to put a face on it."
It’s a team effort
A team approach extends throughout the HMSA organization, Bojorquez notes.
At the intake level, Dullin looks closely at cases to determine if they should be diverted to the disease management or behavioral health programs. "Our whole intent is not to duplicate something that is already in place," she says.
"It’s not unlikely that we might have a member who is diabetic, has congestive heart failure, and is at risk for end-stage renal disease and depression," Bojorquez says. "Is that person going to have four case managers?"
Case management rounds
Representatives from the different programs meet monthly to discuss complex cases, decide who has the best relationship with the member, and make that person the lead for the case, she says.
"The others take a back seat, and she becomes the primary contact," Bojorquez explains. "The patient might remain on other caseloads, but to avoid duplication of services, those case managers don’t touch the case without coordinating with the lead case manager."
Meanwhile, the entire case management staff meet weekly for "case management rounds," she continues. "We present cases and give each other feedback. It’s a vital piece of the program."
If a case is complex, or there may need to be a referral outside the network, Bojorquez adds, someone from HMSA’s clinical review area may join the discussion.
The smallness of the unit engenders a strong camaraderie, Dullin says, with staff members often asking each other, "Have you ever had to deal with this?" or "What’s your recommendation?"
"Our work in case management is hard at times, but in the majority of cases, the results are favorable for both patients and family. The job provides a real sense of satisfaction," she points out.
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