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In an effort to better serve its chronically ill and catastrophically injured members, Phoenix-based Blue Cross Blue Shield of Arizona (BCBSA) has switched its case management from a service-driven model to a proactive, population-based, member-driven program.
The move shifted utilization management functions away from the case managers and onto the utilization management nurses. The result is that the case managers’ time is freed up to actually devote to care management activities.
Now, instead of waiting for the provider to file a claim or call for case management services, the company takes a proactive approach, seeking referrals from providers, internal staff, and the members themselves and examining laboratory and pharmacy data to determine if a member is receiving tests or drugs that indicate a chronic problem.
The case managers work with members on goal setting and long-term care planning.
Members are happy with the change. In fact, 97% of members who responded to a satisfaction survey report being "very satisfied" or "somewhat satisfied" with case management services. The survey was conducted by an independent research company.
Before the switch, a request for benefits triggered case management.
"We knew we were missing some people with chronic diseases who were not yet using the resources or who had catastrophic events and were well into care before the insurance company got involved," says Barbara Guerriero, RN, MA, vice president of medical services.
There were no pre-certification requirements for emergency services, so the company had no way of knowing that a member had been seriously injured until the hospital bills started coming in.
Now, although there still is no pre-certification for emergency admissions, the company may be notified when a member is hospitalized and the case managers get involved with discharge planning and helping the members understand their benefits.
The program was revised in August 2001. The goal is to involve 1% to 3% of the member population in the care management process. "We’re still getting our internal infrastructure finalized to make sure that all referral processes are working," she says.
Referrals come from claims data, from providers that include physicians, skilled nursing facilities and rehabilitation facilities, from the utilization management staff at hospitals, and from internal staff.
The company has a case management referral form available to all employees.
"If people in other departments are aware of a member who would be a candidate for case management, they can send a referral form on the computer. It has been a good resource for us," Guerriero says.
The utilization management team and case management worked together to develop an integrated approach so that when the utilization management staff encounter a patient with a chronic disease or a multiple trauma, they alert case management. "Utilization management has ended up being a strong resource for us, and we’re not tying up the case managers’ time handling utilization management activities," Guerriero says.
To assess the results of its new case management approach, the insurer contracted with an independent research company, which sent out two sets of satisfaction surveys — one to members and one to providers.
The insurer originally planned to send out an annual survey, but the results of the first survey showed that people who had been in case management for a short period of time were unable to give meaningful data when the services were received months earlier.
Now BCBSA sends out satisfaction surveys 30 days after members are discharged from case management.
The insurer sent its first satisfaction surveys to hospitals, skilled nursing facilities, and inpatient rehabilitation facilities — "wherever we send a lot of our members," Guerriero says.
The results indicated that there was some confusion about who to contact on which of the insurer’s multiple insurance products. As a result, the insurer came up with a frequently asked questions (FAQ) document based on the feedback received from the surveys. The FAQ was distributed to case management or utilization management at all facilities.
A follow-up survey is planned for late summer to see how the FAQ document was received.
BCBSA has received accreditation for its case management services from URAC, the American Accreditation HealthCare Commission, based in Washington, DC.
"URAC accreditation is a significant achievement for the organization because it validates our dedication to providing the best possible service to our customers, says Gary Smethers, MD, senior vice president and chief medical officer.