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Comprehensive program bridges gap between CM, DM
Departments work together on integrated plan
Often in health plans, disease management is in one silo, case management is in another, pharmacy management is in another, and they may not interrelate.
Regence Blue Cross Blue Shield of Oregon (BCBSO) is trying to change all that by creating a comprehensive medical management program that includes case management, disease management, and other programs, including network design and physician education.
The data-driven program helps bridge the gap between case management and disease management, providing case management interventions across the continuum.
"We try to use the information we have gleaned to pull the whole process together," says Patrice Korjenek, PhD, assistant vice president of health economics for the Portland-based health plan.
The medical, case management, and disease management staff at Regence BCBSO get together monthly to discuss the groups they are working with possible interventions that would be beneficial, and who should be handling a typical member’s care. For instance, members in case management who are too ill to be in disease management are transitioned after they improve.
Korjenek’s department examines claims data by employer groups to identify the conditions that have the highest cost for each company. Then the disease management and case management staff come up with an integrated implementation plan and communication strategy, tailored to the specific employer.
For example, one employer was concerned about its back surgery expenses and wanted a pilot project to try to cut costs, says Sonja Thygeson, BS, MPH, manager, disease management programs.
The plan Regence BCBSO came up with included collaboration with the health promotions department to develop educational materials, a disease management program that followed specific protocols, and a case management program that provides interventions when needed.
"Orthopedics was a costly condition for this employer group. When we dug deeper, we found that back surgery was a significant driver. We felt like interventions for low back pain could make a bigger impact than interventions for other conditions," Thygeson says.
The back pain program is coordinated internally at Regence BCBSO with the help of a vendor that does telephonic health coaching specifically designed for people who are having back problems such as herniated disk and may be considering surgery.
"We are working through our health economics department to identify people through claims data who may be on the path for back surgery," Thygeson says.
When members are identified as a potential for back surgery, case management staff contacts them, have them fill out an assessment, and stratify them. If the members are having low back pain but it’s not severe and they haven’t been considering surgery, Regence BCBSO sends them basic educational materials developed by the insurer’s health promotions department. These include home treatment and self-care for managing back pain.
The case managers act as intermediary and communicate information to the members.
If the members are considering surgery, they are enrolled in the vendor program and work with a health coach who helps them understand their treatment options and make an informed decision.
Regence BCBSO reports regularly to employer groups, including data from case management and disease management along with pharmacy data.
"The employer is able to look at all our medical management intervention strategies and the results all at one time," Korjenek says.