Company gains physician support by paying them

Program encourages MDs to work with CMs

The case management department of Blue Cross and Blue Shield of Rhode Island has taken a unique approach to ensuring the physicians will collaborate with their case managers — they pay them for their time.

"Some risk group contracts have a provision that reimburses providers for a 15-minute initial consultation with a case manager. We know their time is valuable, and we feel their input is valuable as well," says Yvette St. Jean, RN, BS, CM, operations leader for the case management department.

The physician reimbursement program was rolled out earlier this year.

If a physician agrees to consult over the telephone with a case manager to help develop a plan of care for the member, the company reimburses the physician for a 15-minute office visit.

Whenever possible, the nurse case managers collaborate with the primary care physicians treating the members to develop a plan of care.

"We need to get physician input into the patient plan. We’re also hoping that if the physician has a positive experience with the case manager, he or she will refer more patients for case management," St. Jean adds.

Some physicians already are referring members to case management. The insurer wants to increase these numbers as well as the number of members who participate in the program.

Presently, only about three or four members out of 10 who are identified for case management ultimately participate in the program. The case managers are unable to reach some. Others want to get approval from their physicians.

The company is working to identify reasons some members may not want to participate. In some cases, members agree to participate when they are called but become reluctant when asked to fill out the forms.

In many cases, when the case manager contacts members who have been identified for case management, the member wants to check with the physician before enrolling.

"We hope that we can encourage the physicians to encourage the members to participate and that we’ll get more members enrolled," St. Jean adds.

The case management department has developed a form to send to the provider in advance of the phone call so they can use their time more efficiently.

For instance, members may indicate that they are confused about the dosage and frequency of their medication. "We include this on the chart so the physician can have any information we need handy when the case managers call," says Paula Blanchard, RN, CCM, case management team leader.

Blue Cross and Blue Shield of Rhode Island’s case management department was one of the first three Blue Cross plans nationwide to receive the highest accreditation for case management from Washington, DC-based URAC.

"We’re most proud of our URAC accreditation. We were the first in the state of Rhode Island to achieve accreditation for our case management department," St. Jean says.

Going through the accreditation process helped improve consistency and assure quality in addition to assuring the members that the program is solid, St. Jean adds.

One of the biggest changes the case management department has made to achieve URAC accreditation has been to dedicate a person to quality improvement.

"We had a good foundation to start with, and going for URAC accreditation helped us to make sure everyone throughout the company was on the same page," St. Jean says.

Triggers for case management

Blue Cross and Blue Shield of Rhode Island’s case management department includes 20 nurse case managers and two social workers.

The insurer’s homegrown software system was designed so that members who are treated under selected ICD-9 codes automatically are triggered for case managers.

Some of the criteria for inclusion in case management include asthma, diabetes, congestive heart failure, potential for transplant, failure to thrive in infant and children, and prenatal complications.

The system triggers an automatic referral if members are admitted to the hospital twice within a six-month period.

The system also alerts case managers when a member has multiple emergency department visits or multiple hospital visits with a high dollar cost.

The insurer’s on-site nurses who handle the concurrent review and work with the discharge planners at the hospitals also help identify members who would be appropriate for case management.

"Right now, we’re identifying members for case management after the fact, based on claims data. We want to revise the system to take a more proactive approach," St. Jean says.

When a member is identified for case management, a nurse case manager calls him or her for follow-up.

"The program is voluntary on the part of the members. We offer the program to them and inform them of their right not to participate," Blanchard says.

The software system has an assessment template that the case managers use when they interview the members. The nurse and the member decide together if the member will benefit from the program.

Members receive an introductory packet that includes written consent to participate in the program along with appropriate education materials.

"The nurses encourage the members to sign the consent form and agree to participate," Blanchard says.

"What our nurse case managers offer is education. They also help members find external resources they can utilize for services that we don’t cover," she adds.

Two of the nurse case managers are specialists in managing the care of pediatric patients. One case manager is assigned to transplant patients and two to prenatal care.

"The rest of the nurse case managers handle a mix of patients, but some also have specialties. For instance, we know that some nurses are stronger in cardiology, so we triage those cases to them," Blanchard says.

The social workers help the nurse case managers find community resources and help members with their psychosocial issues.

The first social worker was hired to work with the Medicaid population. The plan has begun using social workers for all lines of business and is recruiting for an additional social worker.

"They are of tremendous value to our program. There are so many issues that affect our members that the social workers can help with," Blanchard reports.

The nurse case managers and social workers have weekly meetings with one of the medical directors and a psychologist to discuss difficult cases. "The team gets together and brainstorms about how to manage their patients," she points out.

Until June 2003, Blue Cross and Blue Shield of Rhode Island had a separate case management department for the Medicare + Choice members. Case management services for all of the company’s product lines have been combined and all the staff cross-trained.

"We spend a lot of time educating the staff on member benefits and regulations that apply to the Medicare population and might be different from other populations, such as the rules issued by the Centers for Medicare & Medicaid Services," St. Jean says.

When the company’s case management department was established in 1997, there were fewer case managers and no sense of direction, Blanchard notes. "Different case managers contacted the members and asked different things. It was confusing to everyone," she says.

One of the first steps was to design assessment templates for all the case managers to follow so everyone was collecting the same information about each patient.

The department is working to come up with some outcomes measures to demonstrate return on investment, cost savings, and improvement in members’ quality of life.

"The software system we have documents everything in case notes, which makes it difficult to come up with outcomes unless you manually abstract the data," St. Jean says.

The case management department has good results from patient satisfaction studies but wants to be able to put a dollar figure on its achievements.

The nurses do a lot of disease-specific education and work with members on medication compliance. "It’s hard to put a price tag on changing someone’s behavior," St. Jean adds.

The department struggles with state regulations that limit some of the utilization review activities the case management department can do for publicly funded members.

For instance, in the past, when a member received home care or needed durable medical equipment, the case managers could coordinate it. Now, under Rhode Island law, the requests for durable medical equipment and home care for publicly funded members have to be sent to a separate department for authorization.