Blue Cross Blue Shield of South Carolina
Complex Case Management Program
Bill Thar, MD, MPH
Ashby Jordan, MD
Vice President of Medical Affairs
(803) 788-0222 x42938
"We are rapidly moving away from pre-certification, which I call Mother-May-I Managed Care, toward a case management/disease management model. Weíve identified a population with specific needs, and weíve developed a program to meet their needs efficiently. I think thatís the model for the way insurance benefits will be structured in the future."
ó Ashby Jordan, MD
The mission of Complex Case Management (CCM) is to provide patients with the services they need and want. There is an attempt by the insurance industry to manage down costs. The result from CCMís work is "we do tend to save money by avoiding hospitalization and emergency room costs. That, however, is a secondary goal."
Franklin Health is a Complex Case Management provider that contracts with Blue Cross Blue Shield of South Carolina (BCBSSC) to provide treatment to the most critically ill of Blue Crossís clientele. Daily, Franklin Health takes a download of patients from BCBSSCís pre-certification process patients, to cull the list to see which clients are catastrophically ill. From this list of patients, if the patient and family are interested, a representative from Franklin Health meets with the client to offer their services. Basically they offer to deliver patient information and options, such as advance directives, and goals for symptom management. Franklin Health has a cadre of nurses trained to work with the sickest patients. If the family agrees to be served by a nurse from Franklin Health, in co-operation with one of the case managers from BCBSSC, Blue Cross contracts that case for service with Franklin Health.
Out of that program at Franklin Health, Mount Sinai Hospital in New York wanted to use the nursing service as a test, taking a cadre of nurses and giving them extra training in end-of-life care to see if that would improve patient care.
Any client of Blue Cross is available for this program, from the youngest neonates to the elderly. The program tries to move people out of the hospital, as long as everyone agrees that that course of action will not be to the detriment of the patient. Almost every service is covered. The company will consider anything to keep patients at home. Any expenditure, from medical equipment to an air-conditioner, may be found appropriate if it can be shown that it will be more cost-effective than a hospital stay. For example, Ashby Jordan, MD says, "if a patient is dying of cancer, if we can keep them comfortable at home, we will." The only dollar limits are those dictated by the patientís policy limit, or the planís limits. The options for types of coverage are unlimited. The program can be made to fit into various models.
A nurse, on location with the patient and family, manages care of the patient. Under typical circumstances a patientís access to pharmacy or services is often limited. The Franklin Health nurses take control of their cases to see that their patient receives whatever services he or she needs.
At Blue Cross, one nurse and one nurse case manager is dedicated full time to Franklin Health. Jordan works on cases, as the need arises. The rest of the employees who staff this program are Franklin Health employees. Blue Cross has added no new staff.
Blue Cross went to Franklin Health to request information about their services. Franklin Health made several presentations, and they were selected to serve BCBSSCís clients.
Those who work in the Managed Care Division at BCBS were the programís champions. They recognized that Blue Crossís case management function was incomplete. The typical case manager didnít address the critically ill population, which was a very high-cost population. The managed care division was effective because its people had the freedom to be innovative. Jordan believes thatís what it takes.
The system in South Carolina is seen as innovative and flexible, so there is an environment there in which people are allowed to try different things to see what works.
Altogether, BCBSSC provides benefits to 1.3 million people. Most of those are administrative services only. But one-third, or about 400,000, are fully insured by BC. The company overlays managed care activitiesóan extension of case management.
The company attempts to assist people by managing their illnesses. In order to initiate this program, no plan or benefit changes were made. Complex Case Management uses the plan of benefits a client already has. If the client exceeds the allowance for hospice or home health care, they are placed in alternative treatment plans, provided the patient chooses to stay at home, which is more cost effective. The company tries to "manage costs down" while providing what the patient needs.
Two palliative care doctors from Mount Sinai hospital in New York, Diane Meier, MD and R. Sean Morrison, MD, were awarded a grant from The Robert Wood Johnson Foundation to contract with Franklin Health and track the efficiency of the nurses trained in palliative care against the non-palliative care trained nurses treating patients with catastrophic illness in the Complex Case Management program. They questioned whether this model could make a difference in how people perceive the end of their life, and how people die.
Initially, BCBS needed a third party to administer the program for them. Dr. Jordan under-stands that perception is very important. "We donít want to be perceived as withholding care. Health plans can get into considerable conflict of interest when theyíre both the provider of care and the insurer. This is one of the greatest sensitivities we face. Also, we must be sensitive to families and patients in providing options for care. We want to be perceived as offering people options and not being directive. If we become directive, we will miss what the patient wants. This is not for every patient. You canít make choices for people, but we want people to make informed choices."
Overall, Franklin Health Plan reports to BCBSSC. In the first year, their data was that they had saved $1.2 million of catastrophic case management, "but thatís a fuzzy figure," Jordan said. "Itís avoided cost, and that is impossible to determine. Intuitively everyone believes itís working. The senior executives all say that even if itís cost-neutral, rather than cost-saving, itís worth doing because itís the right thing to do."
Diane Meier and Sean Morrison are looking at outcome measures of:
Their utilization measures are
Several Franklin Health case management nurses have been formally trained in palliative care through this project. A training curriculum has been designed for the nurses and referenced information sheets on palliative care approaches to specific symptoms have been developed for physicians. Part of the nursing care service involves training patient, family and other providers of care.
Selling this voluntary program has been a challenge, according to Dr. Ashby. He says the hard sell has been to members. Initially BCBSSC presented the plan to patients by phone or letter. About 70 percent of those contacted agreed to entering the program. However, one nurse had a 95 percent acceptance rate, and now she is doing all the initial patient contact. The overall acceptance rate has risen to close to 90 percent. Franklin Health markets through its own parameters.
Ashby Jordan feels that this program might evolve. There may be refinement about the patients Franklin Health chooses for intervention. "There is hope for improvement in the whole culture of end-of-life care in South Carolina, as we come to understand a patientís needs at end of life."
The program has the potential to change hospice agencies. "Itís the hospice nurses who really know what needs to be done in a case. The influence of this might expand hospice care beyond the allotted six months of care toward chronic management," says Jordan.
"I see the next wave as more employer groups and people being involved in these programs. Weíre starting to look at other diseases, like diabetes. In South Carolina where there is a large rural poor population, many people canít get to treatment centers so medical staff can manage their chronic illness. We could provide transportation, and that might be cost effective. There is a whole spectrum of services to be provided. Medicare and Medicaid have never approached this kind of method."
Key Elements of Success
Measures of Program Success
Ashby Jordan thinks we need more time and data for this program "to fully understand what we can."
What I Wish I íd Known ...
"One of the lessons learned is that we must be careful about who presents the program to the family. And the other thing itís taught us is that case management should be more patient centered, not physician centered, and certainly not institutionally centered."
This descriptive summary is based on an interview conducted by Susan Butler with Ashby Jordan, MD, June 13, 2001.
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