Health plan, physicians collaborate on care

Pilot project focus: Care for people with diabetes

A unique partnership between a health plan and a physician practice is helping patients with diabetes get the care and resources they need to manage their disease.

The patient-centered medical home pilot project focuses on people with diabetes who are members of BlueCross BlueShield of South Carolina, BlueChoice Health Plan of South Carolina, the State Health Plan, or BlueCross Blue Shield Federal and who are patients of Palmetto Primary Care Physicians in the Charleston, SC, area.

The pilot project began in April using a model that integrates quality improvement, coordinated care management, and patient educational services into primary care practices.

Case managers located in the physician practice corporate business office act as liaisons between individual physicians and their patients between visits. They collaborate with the health plan's disease management nurses and certified diabetes educators to help patients comply with their treatment plan, receive the recommended tests and procedures, and reduce gaps in care. The physician office-based case managers contact the patients by telephone to help them schedule appointments with specialists and access community resources when necessary.

"We believe that if patients become more educated and better able to self-manage their disease and physicians are enabled to deliver evidence-based care, patients will experience fewer hospitalizations and emergency room visits and enjoy a better quality of life," says Laura Long, MD, MPH, vice president of clinical quality and health management for BlueCross BlueShield of South Carolina.

The program should reult in overall lower costs for employers and less absenteeism as well, she adds.

"Our employers are interested in patients being healthier and at work. They're looking beyond lowering their costs for health care. They want their employees to feel good on the job so they can be more productive in the workplace," she says.

Palmetto Primary Care Physicians receives the traditional fee-for-service reimbursement for the care they provide patients, as well as an additional fee per participant, per month that allows them to fund the case management program.

In addition, through BlueCross BlueShield of South Carolina's pay-for-performance program, the physician practice receives quality-based bonuses, which reward the practice for improving quality and outcomes.

"Before we began this project, case management wasn't a reimbursable service, so it wasn't practical for the physician practices to have case managers. By realigning reimbursement, it allows them to provide a different type of service to support their patients and to take a more proactive approach to care. It helps the physicians focus on delivering evidence-based care and quality outcomes," Long says.

The program takes a proactive approach to care and reaches out to all patients who have been identified with Type 1 or Type 2 diabetes, Long says.

"In the past, programs focused on the most complex patients. All patients are eligible for this program. Rather than just treating the patients who walk in the door, the program also reaches out to the patients who are not coming in for services and helps them overcome the obstacles to seeking care," Long says.

Once patients are identified for the program, they receive a welcome letter from the physician practice and the health plan. The introductory packet includes information on the physician practice's extended care hours, an offer for a free glucometer from the insurer, and a blood sugar tracking booklet.

The case manager follows up with a telephone call to ascertain the patient's willingness to participate. Interested patients receive another packet with information on diabetes and tips for better nutrition, diet, and exercise.

The program is an opt-out program to which most have responded favorably when the case managers call to explain the project, says Amber Winkler, MHA, case manager with Palmetto Primary Care Physicians.

After the initial call, case management outreach is customized based on the needs and requests of the patients.

The physician-based case managers are non-clinical staff who provide support and resources for the patients and work with the BlueCross BlueShield clinical disease managers to ensure that patients get the clinical information they need.

Each physician-based case manager works with about 500 patients.

"We strictly avoid giving patients clinical advice. We concentrate on giving the patient the resources they need to follow their treatment plan," Winkler says.

For instance, the physician-based case managers make sure that the patients keep their appointments to see their doctor, facilitate referrals when needed, make sure that the patients' test results get back in the chart, and help patients overcome obstacles to adherence.

They provide additional resources to the patients, including free week passes and discounts to local gyms; cookbooks; American Diabetes Association-approved nutrition materials such as meal plans; diabetic education classes; free glucometers; discounts on prescriptions or free samples of medication; and patient assistance programs.

Patients have access to the case managers at the corporate office and their physician offices through a secure web-based portal.

"We look at information like their last appointment date, gaps in care, and their most recent laboratory values. We assess what they are willing to learn about and do to manage their condition. When patients need clinical advice, we help them interface with the BlueCross clinical diabetes educator and their physician's office," Winkler says.

The improved communication, coordination, and interaction between the physician offices and the health plan are unprecedented and are a key component of the program, Long says.

In the past, the two organizations tended to work in silos. Now they work together to make sure that the gaps in care are covered, she adds.

"Before we started this program, case managers and disease managers at the health plan level communicated with members and occasionally talked to someone in the physician offices. Under this model, we're tightly interfaced with the case manager in the physician office through an electronic link into the electronic medical record in the doctor's office," Long says.

"It's been a great arrangement for both of us. It's opened up a lot of communication between the physician practice and the insurer. Having direct contact with the insurer is a big help," Winkler adds.

For instance, the arrangement allows the health plan's diabetes educators to access patients' medical record and care plan as they work with them.

"The ability to follow through and the level of communication are significantly enhanced. The diabetes educators can add an electronic sticky note for the case manager or physician based on the conversation they've had with the member and vice versa," Long says.

By having access to the health plan's data, the physician office case manager can tell if the patient actually filled his or her prescription and can discuss it with the patient on the telephone and get the patient medication assistance or a coupon for a prescription if needed.

"We work so closely with the health plan and know our patients so well that we can advise them on the best way to get prescriptions or supplies. We have access to each patient's individual coverage so we can advise the patients what is best for them," Winkler says.

For instance, the case managers have suggested that patients consider generic drugs or a different glucometer because they would be covered under their plans.

One patient was paying out of pocket for his glucometer strips. Winkler advised him that his health plan would pay for the strips if he got a prescription for them and paid the copay.

"Benefits can be so complex and so difficult for patients to understand. We try to work out the best way for the patient to get what they need and pay for it so they will keep following their treatment plan," Winkler says.

The case managers take an individualized approach to each patient's unique situation, identifying why gaps in care occur and working to overcome the barriers.

"We look at whatever we can rearrange to make the situation workable. If the patient is on a high-deductible health plan and can't afford the deductible, we see if they qualify for a patient assistance program," she says.

They assist patients who are eligible for Medicaid supplemental insurance but need help filling out the paperwork.

In some cases, the case managers work with the health plan to get an out-of-contract social worker visit authorized as an alternative treatment plan.

"Within this pilot, we have the ability to be flexible on a case-by-case basis," Long says.

In one instance, a patient who had lost his job was afraid to come into the office with a broken toe and an infection because of financial problems. The case manager at the physician practice called the health plan to get approval for an office visit and get him help with his medication needs.

"The health plan bridged a gap until the physician office case managers could get other resources in place," Winkler says.

The physician office case managers have compiled a tremendous amount of information on community resources and other programs that can help patients overcome their obstacles to getting care or complying with the treatment plan.

"Since the case managers are in the Charleston area where the patients live, they are able to identify an amazing amount of community resources that help patients overcome the barriers to care. The case managers at Palmetto Primary Care Physicians have wonderful social and organization skills, which help them connect with the patient and identify their needs. Anytime they need us, they can call us in and we'll get involved," Long says.

The physician office case managers work closely with the patients to make their health care dollars stretch.

"Many times when we get to know the patients, we find they are spending money unnecessarily on things that are covered by insurance and are skimping on things that they really need. We utilize every resource we can find to help the patients get what they need to keep their disease under control," Winkler says.

For instance, when the case managers can help patients find transportation assistance or get help with an electric bill, it frees up money to pay for medications, or if patients can get low-cost generic drugs, they can use the money they would have spent on drugs for their copay.

"It's kind of like a shell game, a matter of arranging and maximizing the patient's available dollars. The case managers have been very adept at identifying community and health plan resources to fill the gaps in care," Long says.