Three-pronged approach improves care for Medicaid members

Proactive case management replaced traditional UM services 

Keystone Mercy Health Plan, Pennsylvania’s largest Medicaid managed care plan, takes a proactive approach to preventing and managing illnesses, injuries, and utilization among its 285,000 members by providing targeted case management and outreach to members with chronic conditions.

Keystone Mercy, with headquarters in Philadelphia, provides coverage for 285,000 Medicaid recipients in five counties in southeastern Pennsylvania.

The health plan revamped its services to members a year ago, replacing its traditional utilization management model with a three-pronged plan that provides care management to its pediatric population, members with chronic conditions, and those who are at risk for major health care services.

"We realized that the traditional model of utilization management and short, episodic case management was not reaching all the Medicaid members we needed to reach and was a reactive model. We looked at our population and their needs and how we could be more proactive in serving them," says Jane Israel, RN, BSBA, CCM, CPHQ, vice president of clinical services for Keystone Mercy.

Before the reorganization, Keystone Mercy provided traditional health plan services — utilization management, prior authorization, and short-term case management — for members who needed post-discharge services such as infusion or home health services.

"We weren’t looking at proactive management. We relied on the physician, hospital, or home health agency to trigger a referral to case management," Israel says.

Under the new model, the health plan identifies people who are likely to need care and provides case management and disease management services to help prevent them from needing intensive interventions, she notes.

It’s too early for the health plan to have hard outcomes data, but a pilot project showed "compelling results that indicated it’s much more cost-effective to manage members in this manner," Israel says.

Before developing the new member-centric model, the health plan analyzed all its claims data using a predictive modeling program to identify members who needed outreach services, based on the severity of their illness and other needs.

"We identified the types of diseases and conditions affecting our population and used that information to develop programs to meet the needs of our members," Israel adds.

The health plan uses many methods to reach the Medicaid population that qualifies for its case management programs, including telephone calls, mailed reminders, a newsletter, community outreach, and partnering with the members’ primary care physicians.

If they don’t reach members through telephone calls or mailings, the case managers work with the primary care physician to try to contact the member.

The case managers are required to attend continuing inservice education and training about the cultural issues and ethnic beliefs within the population that can influence members’ willingness to obtain and comply with medical treatment.

The health plan’s member outreach starts at birth with a pediatric case management program that focuses on early preventive screening and immunizations, normal growth and development, and safety issues within the home. For instance, providing preventive education to parents about common injuries to toddlers due to falls and poisoning is important, Israel notes.

"With a Medicaid population, it’s important to make sure the parents to have a good understanding of their children’s health care needs and to provide periodic reminders to improve compliance," she says.

When a pediatrician recommends additional services for a child, the case managers follow up to make sure the child receives the services. The health plan’s claims database flags cases when additional services, such as surgery, adaptive equipment, or consultations with a specialist are recommended. If the child doesn’t receive the recommended services within 90 days, the case manager follows up with the parents.

The case managers help parents find a provider within the network, assist with transportation issues, and identify any other barriers to getting care.

The health plan provides disease management for members with chronic disease and high-risk pregnancies through Health Management Corp. (HMC), a Richmond, VA-based national disease management vendor.

"The results of our population profile indicated that we had a large number of members who had certain chronic illnesses, such as asthma and diabetes, who could benefit from education and assistance in managing their diseases," Israel says.

"We identified other members with conditions like chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease who could become high utilizers unless they take steps to modify their lifestyle and manage their chronic illness," she adds.

Keystone Mercy concluded that it would be most cost-efficient to contract with a national vendor who had the telephone support system already in place rather than creating its own disease management programs for large populations.

The population-based disease management programs are augmented by locally developed disease management programs for members with rare, high-cost diseases, such as sickle-cell disease, hemophilia, and HIV/AIDS.

"These disease can be very expensive and they can be kept under control through close management," Israel reports.

For instance, the health plan’s 60 members with hemophilia represent only a small percentage of its 285,000 members, but their care exceeds $10 million a year.

Members are identified through pharmacy data and referred to a case manager who works with them to help them better understand their disease and to help them take steps to keep the disease process under control. The health plan has created a pharmacy network that provides discount prices on the medication.

Members who have very high predictive scores for current and future illnesses are flagged for the company’s care coordinator program. The case managers provide a combination of disease management education, social work services, and case management.

Unlike the members who are identified for the disease management programs, members in the care coordination program have intensive needs. They may need coordination of services among multiple providers. Many are homebound or homeless, and most have problems with transportation.

These members have three or more chronic diseases, are on 10 or more medications, and have an inpatient admission rate five times that of the health plan’s average.

"This population presents a challenge that is not effectively met by providing traditional disease management education," Israel says.

The members are assigned to a care coordinator, a nurse case manager who conducts outreach by mail and by telephone.

She conducts a complete health risk assessment and defines the members’ urgent needs, helping them overcome barriers to care, such as going to routine scheduled appointments with their primary care physician, obtaining prescribed medication, lack of transportation, and obtaining needed medical equipment. The case manager works with the member’s primary care physician to develop a plan of care.

A case management technician, a trained paraprofessional who calls to collect outcome data, assists the care coordinators.

For instance, if a member has diabetes and heart disease, the case management technician will call at regular intervals and collect blood sugar and blood pressure data, alerting the case manager when the indicators are out of the recommended range.

"The case management technicians have a good understanding of medical terms, and many have experience as medical assistants in a physician office. We look at them as being case management extenders who help us maximize the number of members we can touch," Israel says.