- Email: [email protected]
Direct to consumer case management
MARKETING by Paul Kaplan, MD
C
ase management (CM) has been viewed within the insurance industry as a means to improve
the health status of members and reduce potential claims expenses. This model, developed decades ago, has proven effective. Initially, case managers worked for insurance carriers (health or disability carriers), and their major function was to interact with the members who had high dollar claims. After CM became entrenched within the insurance industry, case managers broadened their horizons and started working directly for physician groups that had dollars at risk if the cost of medical care exceeded certain amounts. July/August 2001
Currently, case managers are primarily involved in using their skills to find ways to educate patients, keep them healthy, offer alternative sites of care if they are sick, and determine the most cost-efficient care setting while patients are convalescing. The principles underlying the work remain the same regardless of employer. The problem with the model outlined above is that case managers interact only with the members who trigger certain preset criteria. These could include patients who exceed dollar limits on their claims or have recurrent hospitalizations or specific, predefined diseases. Many of these patients already are severely ill, and the best a case manager may do is minimize future claim costs. For this population of patients, TCM 83
the case manager will never be able to avoid claim costs entirely. In the same way that the insurance industry is looking at demand management and population management as ways to control health care costs, case managers should use these concepts to improve the services they provide to patients. In a demand management program, patients call for help or advice if they think they need it. Why should patients not be able to call a case manager for help if they are in trouble or perceive they are heading toward a problem? Case managers traditionally have thought of the insurance industry as their customers. Their focus has been working for an insurance company to control medical costs. They instead should think of the patients as their customers, even though patients do not pay them directly for their services. Professionals tend to market themselves to the population who is going to purchase their products or services. However, in this instance, case managers should
market themselves directly to patients because the more effectively they can work with patients, the more likely they are to keep their customers (the insurance companies) happy. Case managers should advertise their training, expertise, and availability directly to the patients. Patients then would have someone they could call if they thought they needed help. Just because a patient does not have a diagnosis on an insurance company’s trigger list for CM or has not exceeded a dollar amount on her medical claims does not mean she would not benefit from CM services. In fact, such patients are more likely to be compliant with instructions given to them because they initiated contact. Many studies on readiness to change have shown that patients who seek out care are signaling their willingness to work with their health care providers. By allowing patients the opportunity to call for CM help, the insurance company is sending a signal that patients are a
5666 Clymer Road Quakertown PA 18951
A
n individual with a neurological impairment, especially a traumatic brain injury, is the focus of Success Rehabilitation's programs.
O
ur goal is to help clients obtain a realistic, maximum level of independent functioning in the least restrictive community environment ~ one which advances individual productivity and well-being. Success Rehabilitation's cost-effective programs include: Residential Programs • Transitional • Extended Care • Respite Day Treatment Program Outpatient Program Home-Based Program For the rehabilitation needs of your clients with traumatic brain injury, call the experts at... 215.538.3488 • Fax 215.538.8692 • e-mail: [email protected] TCM 84
July/August 2001
vital part of the equation and they should be included in the decision-making. Patients will be more willing to listen to the options outlined for them by a case manager if they initiate the call than they would if a case manager called them unexpectedly, summarized her knowledge of their health issues, and told them how and where the insurance company would like them treated in the future. This strategy also empowers the patient to feel more in control of the disease process. Patients who initiate contact with case managers are more willing to allow them to explore the psychosocial issues affecting their illness and thus gain a better understanding of how to help them avoid future exacerbations. People intuitively trust that, when they dial a phone number, they will reach the person they assumed they were dialing. However, when someone from an insurance company calls without warning and tries to initiate a conversation about very personal matters, an element of mistrust inevitably arises. This approach
is a poor way to start a relationship with a stranger.
service if we educate them intensively about the CM program.
Insurance companies are being graded by more than just their ability to pay claims in a timely manner. Patients are being asked to rate their insurance company on its proactive member contact. By advertising the fact that case managers are available to help patients navigate their way through the very confusing health care system, the health insurance plan will be perceived by its membership as being proactive in this important area.
Other ways to get patients to enroll in CM before they are sick enough to trigger the insurance company criteria include marketing services to the network physicians. If done correctly, the physicians will use the services for the members they think will continue to require medical intervention. Some insurance companies assign a case manager to a group of physician practices. The physicians are given this person’s phone number and told to call if they need assistance managing a patient. The case manager also proactively contacts the physicians’ office and reminds the nursing staff she is available.
Case managers may market themselves directly to patients in several way. At Blue Cross Blue Shield of Delaware, we educate our members about CM and provide a phone number they can call to speak directly with a case manager. Our intent is to create a pilot study by which we will market the availability of CM services to a member when he joins our company or renews his contract with us. We want to ascertain what percentage of members will take advantage of the
Individual case managers also play a vital role in reaching out to members. Insurance companies need to realize that patients regard the case managers who work for that company with a degree of suspicion. Their assumption is the case managers will put the interests of their employer before those of
the patients. If the insurance company wanted, it could contract with these individual case managers and pay them for their work. Even though someone other than the insurance company employee would be performing the CM services, this situation still would be win/win. The insurance company would benefit because the patient would receive CM services, which still would control claim costs. The patient also would win because he would receive services from a case manager of his choice. In conclusion, health insurance companies are relying on case managers to lead the way toward greater claims savings. To fulfill this mandate, case managers need to start reaching out directly to their true customers, the patients. ❑ Paul Kaplan, MD, is the chief medical officer for Blue Cross Blue Shield of Delaware. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/117488 doi:10.1067/mcm.2001.117488
July/August 2001
TCM 85
C
ase management (CM) has been viewed within the insurance industry as a means to improve
the health status of members and reduce potential claims expenses. This model, developed decades ago, has proven effective. Initially, case managers worked for insurance carriers (health or disability carriers), and their major function was to interact with the members who had high dollar claims. After CM became entrenched within the insurance industry, case managers broadened their horizons and started working directly for physician groups that had dollars at risk if the cost of medical care exceeded certain amounts. July/August 2001
Currently, case managers are primarily involved in using their skills to find ways to educate patients, keep them healthy, offer alternative sites of care if they are sick, and determine the most cost-efficient care setting while patients are convalescing. The principles underlying the work remain the same regardless of employer. The problem with the model outlined above is that case managers interact only with the members who trigger certain preset criteria. These could include patients who exceed dollar limits on their claims or have recurrent hospitalizations or specific, predefined diseases. Many of these patients already are severely ill, and the best a case manager may do is minimize future claim costs. For this population of patients, TCM 83
the case manager will never be able to avoid claim costs entirely. In the same way that the insurance industry is looking at demand management and population management as ways to control health care costs, case managers should use these concepts to improve the services they provide to patients. In a demand management program, patients call for help or advice if they think they need it. Why should patients not be able to call a case manager for help if they are in trouble or perceive they are heading toward a problem? Case managers traditionally have thought of the insurance industry as their customers. Their focus has been working for an insurance company to control medical costs. They instead should think of the patients as their customers, even though patients do not pay them directly for their services. Professionals tend to market themselves to the population who is going to purchase their products or services. However, in this instance, case managers should
market themselves directly to patients because the more effectively they can work with patients, the more likely they are to keep their customers (the insurance companies) happy. Case managers should advertise their training, expertise, and availability directly to the patients. Patients then would have someone they could call if they thought they needed help. Just because a patient does not have a diagnosis on an insurance company’s trigger list for CM or has not exceeded a dollar amount on her medical claims does not mean she would not benefit from CM services. In fact, such patients are more likely to be compliant with instructions given to them because they initiated contact. Many studies on readiness to change have shown that patients who seek out care are signaling their willingness to work with their health care providers. By allowing patients the opportunity to call for CM help, the insurance company is sending a signal that patients are a
5666 Clymer Road Quakertown PA 18951
A
n individual with a neurological impairment, especially a traumatic brain injury, is the focus of Success Rehabilitation's programs.
O
ur goal is to help clients obtain a realistic, maximum level of independent functioning in the least restrictive community environment ~ one which advances individual productivity and well-being. Success Rehabilitation's cost-effective programs include: Residential Programs • Transitional • Extended Care • Respite Day Treatment Program Outpatient Program Home-Based Program For the rehabilitation needs of your clients with traumatic brain injury, call the experts at... 215.538.3488 • Fax 215.538.8692 • e-mail: [email protected] TCM 84
July/August 2001
vital part of the equation and they should be included in the decision-making. Patients will be more willing to listen to the options outlined for them by a case manager if they initiate the call than they would if a case manager called them unexpectedly, summarized her knowledge of their health issues, and told them how and where the insurance company would like them treated in the future. This strategy also empowers the patient to feel more in control of the disease process. Patients who initiate contact with case managers are more willing to allow them to explore the psychosocial issues affecting their illness and thus gain a better understanding of how to help them avoid future exacerbations. People intuitively trust that, when they dial a phone number, they will reach the person they assumed they were dialing. However, when someone from an insurance company calls without warning and tries to initiate a conversation about very personal matters, an element of mistrust inevitably arises. This approach
is a poor way to start a relationship with a stranger.
service if we educate them intensively about the CM program.
Insurance companies are being graded by more than just their ability to pay claims in a timely manner. Patients are being asked to rate their insurance company on its proactive member contact. By advertising the fact that case managers are available to help patients navigate their way through the very confusing health care system, the health insurance plan will be perceived by its membership as being proactive in this important area.
Other ways to get patients to enroll in CM before they are sick enough to trigger the insurance company criteria include marketing services to the network physicians. If done correctly, the physicians will use the services for the members they think will continue to require medical intervention. Some insurance companies assign a case manager to a group of physician practices. The physicians are given this person’s phone number and told to call if they need assistance managing a patient. The case manager also proactively contacts the physicians’ office and reminds the nursing staff she is available.
Case managers may market themselves directly to patients in several way. At Blue Cross Blue Shield of Delaware, we educate our members about CM and provide a phone number they can call to speak directly with a case manager. Our intent is to create a pilot study by which we will market the availability of CM services to a member when he joins our company or renews his contract with us. We want to ascertain what percentage of members will take advantage of the
Individual case managers also play a vital role in reaching out to members. Insurance companies need to realize that patients regard the case managers who work for that company with a degree of suspicion. Their assumption is the case managers will put the interests of their employer before those of
the patients. If the insurance company wanted, it could contract with these individual case managers and pay them for their work. Even though someone other than the insurance company employee would be performing the CM services, this situation still would be win/win. The insurance company would benefit because the patient would receive CM services, which still would control claim costs. The patient also would win because he would receive services from a case manager of his choice. In conclusion, health insurance companies are relying on case managers to lead the way toward greater claims savings. To fulfill this mandate, case managers need to start reaching out directly to their true customers, the patients. ❑ Paul Kaplan, MD, is the chief medical officer for Blue Cross Blue Shield of Delaware. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/117488 doi:10.1067/mcm.2001.117488
July/August 2001
TCM 85