Managed Care BCBS

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University of Massachusetts, Boston *

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Oct 30, 2023

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Professional Managed Care Roles for RNs in the Payer Environment Presented by : Kathie Sliney, RN, BSN Clinical Training Specialist , BCBSMA Kathy Gardner, RN, MBA Vice President Clinical Operations, BCBSMA

2 Blue Cross Blue Shield of Massachusetts Objectives • Describe the responsibility of a health plan (payer) to achieve the goals of the Triple Aim • Identify 3 roles held by the professional nurse in the payer setting • Explain how the professional nurse can translate clinical skills to impact a member’s care and improve outcomes

3 Blue Cross Blue Shield of Massachusetts What is the Triple Aim? Source: Institute for Healthcare Improvement • Improving the individual experience of care • Improving the health of populations • Reducing the per capita costs of care for populations

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4 Blue Cross Blue Shield of Massachusetts How to improve the individual care experience  Reduce fragmentation of care – assist with care coordination, collaborate and communicate with providers  Assure our policies are evidence-based and align with principles of health equity and “Parity”  Integrate Behavioral Health, Complex Case Management, Disease Management, Prevention and Wellness  Primary Nurse Care Management model

5 Blue Cross Blue Shield of Massachusetts Populations • Groups of individuals defined by geography, condition or other attributes can be considered a population if data are available to track them over time. • Social determinants of health: health literacy, education level, geography, access to care and socioeconomic status can have an adverse impact on health outcomes Population Health Management Data • Health Effectiveness Data Information Set (HEDIS) • Predictive Modeling • Provider Quality (Measuring outcomes of our provider partners) Source: David Nash, MD, MBA, Dean, Jefferson College of Population Health

6 Blue Cross Blue Shield of Massachusetts Reducing per capita cost of care  Value-based contracts and provider partnerships  Focus on preventing avoidable readmissions  Proper utilization through reduction of overutilization and underutilization  “The right care, in the right setting, for the right duration”

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7 Blue Cross Blue Shield of Massachusetts Fully insured accounts: have arrangements in which a licensed insurer provides the administrative services to the employers and pays the cost of benefits for covered services Self-insured vs Fully Insured Self-insured accounts: those with Administrative Service Contracts, arrangements in which an insurer provides administrative services to an employer’s health benefits plan but does not insure the risk of paying benefits to enrollees The account takes on all the risk and pays the claims The insurance company takes on the risks and pays the claims

8 Blue Cross Blue Shield of Massachusetts Clinical Operations Utilization Management Medical Behavioral Health Clinical Appeals Care Management Complex Case Management Disease Management Wellness Coaching

9 Blue Cross Blue Shield of Massachusetts What is Utilization Management? Conduct pre-service, concurrent and post- service reviews of certain medical and behavioral health services Apply evidence- based industry standards, criteria and policies to clinical information to make a determination Participate in interdisciplinary rounds to ensure the member is supported throughout the continuum of care

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10 Blue Cross Blue Shield of Massachusetts How are Cost-Effective Outcomes Achieved? • Transitioning to a more appropriate level of care : for example, Acute Residential to Outpatient for BH. • Accessing providers in our networks • Averting potentially avoidable readmissions : reviewing discharge plan and follow-up care, understanding when to call the provider for a change in symptoms or side effects; having a crisis plan • Increasing utilization : keeping physician appointments, filling prescriptions, encouraging participation in cardiac rehabilitation, consistent participation in therapy • Appropriate utilization : reducing the use of ER as a primary care source, decreasing duplicate tests or treatments

11 Blue Cross Blue Shield of Massachusetts Care Management Programs Complex Care Management - Complex & High Risk - Oncology - High Risk Pregnancy - Pediatrics - Aftercare Chronic Condition Management - Asthma - Congestive Heart Failure - Coronary Artery Disease - Diabetes Behavioral Health Care Management - Substance Use Admissions - Complex Behavioral Case Management - Depression - Aftercare = Population Health Management

12 Blue Cross Blue Shield of Massachusetts Goal of the Care Management Nurse To assist the member in reaching an optimum health care outcome and maximizing their health care benefits, Care Management programs work to: • Use timely, actionable data in predictive modeling to target populations • Identify strategies to overcome barriers to the providers’ plans of care • Lower rates of complications, emergency room visits, inpatient admissions and readmissions • Address identified gaps in care • Collaborate with member or caregiver to develop a focused and individualized care plan to promote self-management • Improve member health status and quality of life • Help ensure “the right care, in the right setting, for the right duration” It all starts when the member takes our call

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13 Blue Cross Blue Shield of Massachusetts Why Do Members Need Case Management? 1. In the U.S., what percent of adults with diabetes follow all of the recommendations of their care team, in a sense doing “everything right”? 2. What is the average amount of time that people with chronic conditions stay 100 % adherent? 3. What do you think is the average length of an appointment with a provider? 4. How often do discharge plans get communicated to PCPs? 5. What percentage of people coming home from the hospital fully understand their diagnosis? 2% 6 months 15 minutes 20% 59%

14 Blue Cross Blue Shield of Massachusetts FOR EVERYONE FOR COMPLEX AND HIGH-RISK MEMBERS Wellness Programs • Physical activity • Healthy eating • Stress • Tobacco cessation • Weight management • Preventive care • Cancer screening reminders Clinical outreach • Co-morbidities • Complex • Behavioral Health • Substance Use • High-cost • Oncology Different people have different challenges. Therefore our outreach is different depending on the members’ needs.

15 Blue Cross Blue Shield of Massachusetts More ways to apply Nursing Skills Cost & Trend Forensic review and analysis Identify overuse, misuse and abuse Help to drive claim costs down Medical Policy Develop policies to ensure covered services are evidence-based Quality & Compliance Improve operational excellence and health outcomes Support the accreditation process to meet or exceed requirements Consumer Health Analyze population health data Create initiatives to target needs of specific groups and areas of impact

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16 Blue Cross Blue Shield of Massachusetts Focusing on health outcomes and targeted programs to improve population health Analyzing data to identify and act on cost trends Making the member experience less fragmented and more transparent How do we achieve the Triple Aim goals?

17 Blue Cross Blue Shield of Massachusetts CM Essentials: Overview Questions?

18 Blue Cross Blue Shield of Massachusetts CM Essentials: Overview Sabaté, E. (2003). Adherence to long-term therapies: Evidence for action. Geneva: World Health Organization, p. 26. Tai-Seale, M., McGuire, T. G., & Zhang, W. (2007). Time Allocation in Primary Care Office Visits. Health Services Research , 42 (5), 1871–1894. doi.org/10.1111/j.1475-6773.2006.00689.x Kripalani, S., Lefevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians. Jama, 297(8), 831. doi:10.1001/jama.297.8.831 Horwitz, L. I., Moriarty, J. P., Chen, C., Fogerty, R. L., Brewster, U. C., Kanade, S., Krumholz, H. M. (2013). Quality of discharge practices and patient understanding at an academic medical center. JAMA Internal Medicine, 173(18), 10.1001/jamainternmed.2013.9318. http://doi.org/10.1001/jamainternmed.2013.9318 Citations

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