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Case management: the advocates in your corner

Across the health insurance industry, the biggest challenge case management teams face has been consistent over the years: members’ distrust of insurance companies.

“Sometimes on a cold call, we’ll hear the member say, ‘I don’t want to work with you, because all you’re doing is trying to get information to deny my healthcare,’ says Brenda Hardage. “That’s a stigma that’s been around my entire 30-year career, the big bad insurance company that wants to deny care.’ And that’s just not the case.”

Hardage’s 30 years in nursing include 17 working in case management for Arkansas Blue Cross and Blue Shield. She’s now the clinical executive of strategic innovations and population health, supervising a staff of 200 who are responsible for more than 1.5 million members across the U.S.

She says denial of care is never their goal. Instead, Hardage says case managers work with high-risk members to improve their health, connect them to needed resources and help them manage whatever issues they’re having before the disease progresses or complications arise. Everyone benefits. Improved health is better for members physically and financially, can help manage their employer’s health costs and increase the employee’s productivity at work.

“We are truly looking at members holistically. We’re looking at how can we help our members have better health outcomes by closing the gaps in care, getting preventive screenings, managing their chronic conditions and overall educating them on the healthcare process and helping them navigate the very fractured healthcare system,” she says. Gaps in care are things like missed mammograms or colonoscopies, unfilled prescriptions, not having a primary care provider (PCP) and more.

She says members are often surprised when they learn what case management does; most don’t realize case management is available as part of their health insurance coverage. “I’ve met a lot of people in my career who have said, ‘I didn’t know my insurance company had nurses on staff to help me,’” Hardage says.

In fact, case management at Arkansas Blue Cross encompasses nurses and many other healthcare professionals.

“We are a real interdisciplinary team that tries to put the members in the center and give them the best evidence-based information and support. We take a whole-person approach, and we have a lot of resources. So, for example, if we encounter someone who has social determinants of health (SDOH) issues, we’ll collaborate with our social work team and introduce a social worker to the member. The same if it’s a pharmaceutical issue, or nutrition or diabetes specific. We have a team of professionals who are board-certified in their fields ready to help.

Case study: Helene

Helene (not her real name), 50, had been hospitalized after her blood pressure shot up to critical levels. She had a history of hypertension, hyperlipidemia and tachycardia, plus financial concerns and chronic stress as a caregiver for her son with psychiatric issues. She was frustrated by the cash she had to pay out of pocket for her discharge medications and her difficulties getting reimbursed. She also complained that her PCP and cardiologist did not communicate well with each other.

One of Hardage’s nurse case managers reached out to Helene and found her open to having support improving her health. The case manager formed a personal bond with Helene, who saw her as a trusted advocate.

First, our case management team successfully advocated for her discharge medication reimbursement and contacted her pharmacy to correct her pharmacy benefit information in their system. Her nurse case manager connected Helene to one of our social workers and to behavioral healthcare covered by her health plan through Lucet, our behavioral health vendor. Helene’s case manager explained the benefits of a low-fat, low-sodium diet for her conditions, and her social worker connected her to resources to help with her financial concerns and stress reduction.

For her chronic condition management, Helene’s case manager guided her to our member site, Blueprint Portal, where she could search for a new cardiologist and behavioral health providers. Her case manager also spent considerable time educating Helene on the various aspects of her condition that she can manage from home.

That included educating her on the symptoms, dangers and warning signs associated with her conditions, and how to identify when she needed to contact her PCP to prevent complications. She coached Helene in alternative and no-cost stress reduction-methods, including relaxation and breathing exercises and emphasized the importance of preventive care and keeping regular appointments with her PCP. Helene learned to recite her medications and their timing and dosages and now keeps a printed list of them in her wallet.

For 90 days following her inpatient discharge, Helene’s Arkansas Blue Cross case manager followed up with her monthly to assess her needs and progress. Helene’s now connected to resources to help her manage her conditions and reduce her stress. She’s active in support groups for heart health and mental health, and her low-fat, low-sodium diet has already decreased her bad cholesterol levels by 70 points. Helene’s been able to return to work and has had no more hospital or emergency readmissions.

That’s one success story among thousands, each for a member with unique needs and risks.

Digitally driven with a human touch

Case management is at the heart of Arkansas Blue Cross’ work, intersecting powerful data-driven engines that key in on for which members case management would make the most difference in terms of their health outcomes and costs. The five key areas Arkansas Blue Cross directs our algorithms and proprietary artificial intelligence to focus on are members with:

  • Top 10% highest-cost claims
  • Diabetes to end-stage renal disease
  • Substance use disorder
  • Pre-term birth/labor
  • Major orthopedic surgeries

Members in these areas have been proven to see the greatest return on investment when engaged with case management. Our one-on-one work and advocacy for them as they navigate the healthcare system and try to manage their conditions makes a concrete difference for their health and their medical expenses through sometimes complex diagnoses, multi-phase treatment plans and major health events.

Hardage says that for most of her career case management was primarily reactive, but that’s changing fast. “At first, we case managers didn’t have good insight into the full picture of what was going on with the patient from their claims or any other data,” she explains. “We just reacted when the member got put in the hospital, or if an employer group called for help managing their condition. We’d hear someone had a stroke and was in the hospital, so we’d reach out to them.”

That began to change in 2019 when Arkansas Blue Cross integrated members electronic medical records. Since then, the organization has invested heavily in developing a new Data-Driven Insights department led by health economists and data scientists who pair human analytic insight with machine learning. Today members’ medical records are more secure than ever, but the case management team receives proactive reports about who within a member population are rising-risk patients, including who are most likely to engage with case management and show demonstrable progress.

How can we help?

Case management has chronic condition management programs to help members understand and successfully manage their chronic conditions day-to-day. Another unit within case management is dedicated to high-risk maternity care. These case managers work with pregnant mothers on how to best take care of themselves during pregnancy, lower their risks for pre-term births, pre-eclampsia and other complications of pregnancy, labor and delivery and manage conditions such as gestational diabetes or hypertension that can arise during pregnancy.

Case managers consider SDOH such as the member’s socioeconomic status, whether they live in a metropolitan or rural area and have transportation and how that affects their access to quality healthcare. “Our rising-risk programs are focused on trying to get ahead of potential complications from members’ conditions no matter their socioeconomic status and ward off some potential risks,” Hardage says. “And we’re able to detect and reach particularly vulnerable members who may benefit greatly from some extra help.”

Case study: Maria

Another member, Maria (not her real name), has a rare genetic blood disease. Her provider prescribed infusions of a medicine that costs $2 million per year. Maria’s case manager worked with her to get some background information and find missing medical records needed to qualify her for the medication, developing a rapport with her as they talked.

Maria chose to change providers and on Arkansas Blue Cross’ recommendation, established care with an expert in her rare condition at a local hematology treatment center. Her new specialist approved her to receive the infusions at home, where she would be most comfortable, at significantly less cost. Throughout evaluating different providers and treatment options, Maria’s case manager advocated for her and helped her get the best care for her chronic conditions at a reduced cost and coordinate care between her providers.

Saving millions of dollars while improving lives

Such transitions of care are a frequent way case managers help save patients and employers money. Case managers evaluate where the member can receive the best, most clinically appropriate level of care at the least cost, and help get them transitioned to a better option, sometimes even in the comfort of their own homes. In 2022, successful transitions from high-cost facilities to home infusion, infusion centers or providers’ offices reduced annual treatment costs by $98,000 on average per engaged member across Arkansas Blue Cross’ book of business.

In 2021, the total cost savings from each Arkansas Blue Cross, Health Advantage and BlueAdvantage Administrators of Arkansas case management intervention was $87,896,900. When combined with the totals for other case management, pharmacy and social work specialties, that total climbs to $112,211,043, not including Medicare Advantage members.

First contact

Although the team is multidisciplinary, in most cases the case manager is the member’s primary point of contact. Hardage says that’s important because having different people calling about various aspects of care becomes overwhelming for the member. “Once you’ve built a good relationship with someone, you want to be the driver of that relationship, then have all these other ancillary people giving you information you can give to the member,” she says. “We’ve found it’s much more well-received when you have that bond and trusted relationship.”

Contacting members in the first place can be a major challenge, though. “I’ve been here 17 years. Reaching members has been a challenge the whole time as well as finding out the best way and time to communicate with them,” Hardage says, adding that Arkansas Blue Cross now offers multiple ways to communicate with case management. These include the ArkBlue Connect app, telephone, email and chat.

Accurate contact information

Hardage says it would be enormously helpful for employers to emphasize to their employees that Arkansas Blue Cross needs current contact information for every member on their plan age 18 and older. Even though parents may have their young adult dependent on their health plan, once the dependent turns 18, by law nurse case managers and others at Arkansas Blue Cross cannot discuss their child’s health or claims with them until they have the young adult’s express permission. Creating a Blueprint Portal member profile with correct, preferred contact information for every adult on the plan can help Arkansas Blue Cross support families and reach the right person on the first try.

“It gives me great satisfaction to know I’m able to help people when they’re at their most vulnerable or need the most assistance,” Hardage says, “Whether it’s education or navigation to a health solution, finding a new provider or getting a second opinion, it feels good knowing that we’re able to offer some reassurance and guidance during their time of need.”