Summary:In a pilot program, the national insurer Aetna has placed nurse case managers in 36 primary care practices to work alongside providers in their offices to help manage patients' conditions. Thus far, the program has involved some 20,000 patients, all members of Aetna's Medicare Advantage plan, and has resulted in improved care processes, some improvements in care outcomes, and reduced numbers of hospitalizations.
By Martha Hostetter
Nurses, physician assistants, and other health care professionals are increasingly being added to primary care practices to help meet demand for services and improve the quality of care, particularly for patients with chronic conditions that are difficult to manage through traditional office visits alone. Sometimes, primary care practices hire case managers themselves, often in response to incentives from payers to improve care and control costs. But increasingly over the past decade, private insurers have been employing case managers to help their contracted providers manage patient care.1 In these arrangements, the case managers are usually located off site (i.e., not at physicians' offices). Some payers are experimenting with arrangements in which case managers work in the practices, under the theory that closer collaboration with physicians will produce better results.
This case study focuses on Aetna'a use of "embedded" nurse case managers, who work in primary care practices to help manage care for the insurer's Medicare Advantage members. In collaboration with primary care providers, the case managers develop care plans, monitor ongoing symptoms, and coach patients to manage their conditions—helping to build continuity of care and enabling patients to receive critical tests and procedures. Such efforts have been shown to improve health outcomes and help patients avoid complications and unnecessary hospitalizations.2
Organization and Leadership
Aetna is a national insurer that offers commercial insurance as well as Medicare and Medicaid plans, with some 18.6 million medical members overall. The insurer actively manages care for about 20 percent of its Medicare members, a high rate by industry standards.3 This includes management of complex cases, including patients with multiple conditions, as well as interventions targeted at certain diseases, such as asthma or diabetes.
Randall Krakauer, M.D., Aetna's national Medicare medical director, proposed and championed the use of embedded case managers as a way to improve management of chronic conditions and reduce hospitalizations among its Medicare Advantage members. Marcia Wade, M.D., a senior medical director at Aetna, oversees the pilot program. Thomas Claffey, M.D., is medical director of NovaHealth, an independent practice association based in Portland, Maine, that has had one of Aetna's embedded case managers working in its InterMed multispecialty group practice since January 2008.
Krakauer views this as a pilot program to try to extend and improve upon Aetna's efforts to help their members' access the most appropriate care and control costs.
"We had an extensive program of telephonic case management, which was producing good results, and the case managers were working their best to collaborate with physician offices," Krakauer says. Still, he said, "it's very hard to engage physicians if you just call and say, 'Hi, I'm so and so with Aetna and I'd like to discuss this case with you.' We knew the process could be improved."4
In 2007, Aetna signed its first contract with a physician practice to have a nurse case manager work on site to help manage care of Medicare Advantage patients. The designated case managers, who are all registered nurses, now work with 36 practices—including primary care practices and multispecialty group practices around the nation—reaching some 20,000 Medicare Advantage patients. Although this is a small part of Aetna's total Medicare Advantage membership of 451,000, the insurer is actively expanding the program.
An embedded case manager works exclusively with a practice when they have 1,500 patients enrolled in Aetna's Medicare Advantage plan. In practices with smaller memberships, the case managers spend part of their time on site. The case managers have expertise in attending to the particular needs of older adults, including handling multiple chronic conditions, dementia, and depression. In addition, they receive training in Aetna's "Compassionate Care" program for end-of-life care.
Aetna hires the nurse case managers and negotiates contracts with physicians who are willing to have them work in their office. The practice receives an extra fee, on top of their Medicare Advantage contract, for each patient enrolled in the case management program. It can earn additional incentive payments for meeting quality targets. While each practice works with Aetna to choose targets appropriate to its patient population, they must include measures of recommended health care processes and at least one measure of outcomes. In addition, all practices track the number of hospital admissions and the number of acute-care days for participating patients.
Aetna's team of Medicare case managers identifies patients in need of services through health risk assessments, concurrent review, and predictive modeling. In addition, physicians and other providers can nominate patients whom they believe need help managing their conditions—a process that produces even more timely interventions. "Instead of waiting to have a patients' data go into our system, providers can reach out directly to the case managers to ask for their help," says Wade.
The case manager meets with the practice's clinical team to discuss the needs of the patients selected for the program and to pinpoint any psychosocial barriers to following a plan of care. Case managers then reach out to patients by phone to ensure they have the information and tools needed to follow their care plan. For a 75-year-old woman with mild dementia, arthritis, and diabetes, a case manager would assess whether she and her caregivers are able to provide optimal care. Is her home environment safe? Do her caregivers understand how to look after her, and are they capable of doing so? Is her dementia affecting her ability to handle her medical conditions? The case manager would then check in by telephone on her symptoms, make adjustments to her care regimen, and report back to her physician on her status. This type of follow up might take place several times a week initially, then less often as patients' conditions improve or stabilize. At patients' request, case managers occasionally sit in during office visits to close the loop of communication between themselves, the patients, and their providers.
In addition to outreach and coaching, the case managers review their patients' claims data, pharmacy and laboratory reports, prescriptions, and other information. At least once a month, the case managers run this information through Aetna's ActiveHealth "Care Engines," clinical decision support software that identifies actionable gaps in care on three levels: level one gaps are urgent and serious, such as a potentially lethal drug interaction; level two gaps are serious but not necessarily urgent, such as a diabetes patient whose HbA1c levels are not at desired levels; and level three gaps are routine, such as a 70-year-old woman who has never had a bone density test. Case managers then follow up, as appropriate. They also receive alerts every time one of their physician group's patients is hospitalized. The case manager reaches out to offer discharge planning assistance, and may also notify the physician about the admission.
Claffey, NovaHealth's medical director, chose to participate in this pilot because he was "intrigued by the idea of panel management and having the ability to fundamentally affect the care to this population." He meets each week with the case managers to review the data, answer questions, and discuss improvement projects. Like physicians in other participating practices, he also meets monthly with Aetna's medical directors to discuss how well the program is working and explore ways to strengthen it.
Having the support of the case managers has led some of the practices to develop targeted improvement programs. A medical group in Pennsylvania asked case managers to help monitor anticoagulant outcomes by alerting them when one of their patients is discharged on an anticoagulant medication and then working with them to monitor the patients' progress, especially during the first 30 days after discharge. An Ohio group will be using telemonitoring tools—provided by Aetna and Intel—to keep track of heart failure patients. Patients will use the tools to monitor their blood pressure, pulse, oxygen saturation, and weight and send the information to their case manager, who will review the data and share findings with their physicians as necessary.
The NovaHealth group is piloting an "ideal practice model," including holding office hours seven days a week and instituting a hospital discharge planning process, to try to improve the quality of care and increase patient and provider satisfaction. Aetna's case managers are working with them to implement the model and assess the effectiveness of the approach. The practice is also seeking to improve orthopedic follow-up care, including preventing falls.
The use of embedded case managers appears to have led to improvements in health care quality. Nearly all of the medical groups participating in the embedded care program with over 200 enrolled patients have met their performance targets. These include certain process measures that are designed to be achievable, such as whether patients have follow-up office visits within 30 days of hospital discharge and patients with certain chronic conditions have at least two office visits a year. "The idea is we want them to really happen," Wade says. "And it's amazing: it does take attention to these things to make sure people take the extra effort to ensure that they do—and then a lot of even better stuff can happen." For example, a patient who is seen by his doctor just a day or two after hospital discharge may have his medications straightened out and, with a case manager's help, continue to recover at home without complications.
Participating groups also track certain disease outcomes. For example, NovaHealth's InterMed group practice, which works with an embedded case manager, has achieved improvements on measures of disease control for diabetes and ischemic vascular disease (Exhibits 1 and 2).
The program also has had an impact in terms of avoiding complications and thus reducing the need for hospitalization. In 2009, Aetna's regular case management program—without embedded case managers—resulted in a 31 percent reduction in the number of acute-care days, exclusive of denials, compared with unmanaged Medicare. (These results are on a risk-adjusted basis.) Across all 20,000 participating Medicare Advantage members, the embedded case management program has produced an additional 12 percent reduction in acute-care days to date in 2010.
Participating physicians report that the program saves them time: case managers are able to perform certain tasks, such as linking patients to social services or ensuring they see specialists, that they and their office staff may not have time to do. Physicians also appreciate having greater certainty that their recommendations will be followed and receiving updates on their patients' progress between office visits. For their part, case managers say they save time by not having to play "phone tag" with providers and by gaining direct knowledge of the social and clinical resources in the community.
Having case managers embedded at physicians' offices may increase their ability to effectively manage patient care, compared with typical telephone-based approaches. The improvements seem to come from case managers' enhanced ability to collaborate with physicians and their staff—born from regular, face-to-face contacts and trust that develops over time. Case managers also benefit from working in a data-rich environment—one in which they have easy access to physicians and their staff and can track performance on the agreed-upon quality measures.
"If you see an inpatient on your rounds and write a set of orders, you can have a high level of confidence they will get done," says Krakauer. "If you see the same patient in your office and write some prescriptions, tell them to go get tests, refer them for certain consultations, and ask them to follow-up in a certain number of weeks, you have a relatively low level of confidence this will all get done." While it's not possible to re-create the controlled milieu of a hospital in the community, the close collaboration of case managers and providers makes it more likely that care plans will be followed.
While insurer-led improvement programs can foster collaborative relationships between health plans and their contracted physicians, financial incentives for participation in this kind of program need to be sufficient to garner physicians' attention and make their investment of time worthwhile. That said, Krakauer believes that success is less contingent on the incentives and more a matter of aligning insurers' interests with those of physicians. The program has "changed the nature of Aetna's relationship with physicians," Krakauer says.
Claffey, medical director of NovaHealth, points to the synergy achieved through collaboration between providers and payers. "We on the provider side have trusting relationships with patients, and access to data that health plans don't have," he says. "On the other side, health plans have aggregate data about a panel of patients, and can help identify issues related to hospital readmissions, ED visits, see who is filling prescriptions and who's not."
This approach differs from many pay-for-performance programs in that Aetna has more "skin in the game" than payers typically do under such arrangements; it pays case managers' salaries as well as the provider incentives, and also deploys its own case management resources, such as predictive modeling and clinical decision support. And Aetna works actively to help practices meet and exceed the designated performance targets.
"I think if you just put P4P [pay-for-performance] on top of what physicians are already doing, without making an effort to change the way things are done, you won't have improved much," says Wade. "We try to have a commitment to improve care together—based on the evidence, based on what's been working in other practices."
Claffey of NovaHealth agrees. "This is a lot different than typical pay-for-performance. As this goes along, each party develops confidence that the other is in it for the right reasons—both are working to improve health care delivery, make patients healthier, in a manner that does bring some value to the system."
While this model of case management could be expanded beyond Medicare Advantage patients, there are significant challenges to doing so. Medicare Advantage plans receive additional federal funds, compared with fee-for-service Medicare, to provide additional benefits to enrollees, and thus have the financial resources to invest in full-time case management programs. Generally, case management programs are more easily implemented among Medicare patients, compared with commercially insured patients, because many primary care practices have sufficient numbers of Medicare patients with complex care needs to make the investment worthwhile from a clinical and a financial standpoint.
Most physicians still practice on their own or in small group practices of fewer than 10 physicians. To expand the embedded case management program among such practices, Aetna is looking to develop contracts with "PODs," or pools of doctors willing to take on collective responsibility for a group of patients and work with case managers to improve their care. In this case, the quality incentives would be shared among the group.
Aetna's attempt to form networks of physicians is a step toward the accountable care organizations that are being promoted under the Affordable Care Act.5 The insurer's efforts will be an important test to see how well independent physicians can collaborate with each other as well as with payers to improve patient care—with case managers as the glue that helps hold them together.
For Further Information: Contact Randall Krakauer, M.D., at email@example.com or Marcia Wade, M.D., at firstname.lastname@example.org.
1 N. C. Aizenman, "Insurers Tout Disease Management Programs, But Critics Are Wary," Washington Post, July 20, 2010.
2. S. M. Shortell, R. Gillies, J. Siddique et al., "Improving Chronic Illness Care: A Longitudinal Cohort Analysis of Large Physician Organizations," Medical Care, September 2009 47(9): 932–939.
3. Randall Krakauer personal conversation, based on internal Aetna study.
4. Aetna has also worked with Mary Naylor, Ph.D., R.N., a professor of gerontology at the University of Pennsylvania School of Nursing, to implement Transitional Care Management for its Medicare Advantage members. This program, pioneered by Naylor and developed over a number of years, uses advanced practices nurses to provide comprehensive in-hospital planning and follow-up care, including home visits, for chronically ill older adults. It has been shown to improve health outcomes and reduce costs. M. D. Naylor, P. Hollander Feldman, S. Keating et al., Translating Research into Practice: Transitional Care for Older Adults, Journal of Evaluation in Clinical Practice, December 2009 15(6): 1164–70.
5. In 2012, Medicare will launch a shared savings program to reward primary care physicians, specialists, and hospitals that form accountable care organizations and collaborate in the redesign of care processes, improve care coordination, and promote high-quality, cost-efficient care.
This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution.
The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.
Posted on 7/01/07
Ongoing Case Management Needs in Chronic Management of Multiple Sclerosis
A 42-year-old single female named Katie presents to an ophthalmologist complaining of acute blurred vision and severe pain in her right eye. Physical examination reveals pallor of the right optic nerve, indicative of a possible demyelination process such as multiple sclerosis (MS). An MRI study of the brain with contrast reveals multiple lesions in the left frontal cerebral white matter suggestive of MS. Enhancement of the right optic nerve is also suspicious for optic neuritis.
Optic neuritis is commonly a first symptom of MS. Katie is referred to a general neurologist within her large managed care plan. Based on the MRI findings and physical exam, she is diagnosed with possible relapsing-remitting MS. Without further complications, no treatment is provided. The blurred vision never completely resolves. She subsequently experiences difficulty at work trying to read her computer screen. Katie is advised by her referring physician that she must learn to live with her symptoms until further determinations can be made, and that, at some point, medication management may be required.
A few months later, when hurrying through an airport concourse on her way home from a trip, Katie experiences right leg weakness and total numbness of her right foot. She can barely drive home and crawls across the floor of her condo for fear she will fall. The numbness lasts a couple of days; however, the right leg weakness continues with foot-drag for 6 months. A pins-and-needles sensation remains in her thigh and is intermittent. A second visit to her neurologist determines that this second MS symptom, along with the positive MRI and previous physical findings, confirms a diagnosis of MS.
The neurologist begins Katie on interferon. Self-injection instructions are given — Katie gives herself an injection in the doctor’s office and tolerates it well. She appears confident and comfortable with the procedure but calls the next day complaining of fever, nausea and muscle pain. She also describes redness, swelling and pain at the injection site. She is advised these reactions are common and normal and should go away within 48 hours.
Katie self-injects the next dose of Interferon at home on Saturday but is nervous and has difficulty following the written instructions about how to mix the medication and load the syringe. She drops the needle on the floor and, unsure of what to do, throws the syringe away. There is no spare syringe. She calls the doctor’s office on Monday and they instruct her to resume the injections. She manages the next injection but continues to experience severe flu-like symptoms and injection-site reactions.
Over the course of the next 5 months, Katie becomes depressed and frustrated with the reactions from the interferon and slowly weans herself from the drug. Meanwhile, Katie’s new job causes a switch in health plans. She sees a neurologist who is an MS specialist nearly one year to the date of her initial visit with the first neurologist. She is experiencing her second painful episode of optic neuritis, weakness in her right leg and severe fatigue.
Katie is hospitalized and placed on a 5-day IV course of high-dose corticosteroids to help control the acute exacerbation. Her IV therapy is followed by a gradual tapering dose of prednisone. Her MS specialist helps her get back on an interferon regimen. He prescribes interferon beta-1b and refers Katie to the interferon beta-1b training program, where she receives one-on-one training from an MS-specialized registered nurse. The physician also prescribes amantadine for her fatigue, along with baclofen for spasticity in her right leg.
Three months later in a routine neurological exam, Katie complains of bilateral hand numbness, pain and tingling down the right arm. She is having trouble holding things and fears her MS is progressing. She is also experiencing Lhermitte’s signs. Katie is referred for an EMG study and an MRI of her spine, which conclude that she has bilateral carpal tunnel syndrome and a herniated disc at C6/7. Katie is relieved to hear that her MS has not progressed to her spine.
Katie is referred for surgery to repair the disc. The surgery is successful and totally alleviates her pain; however, she has an MS flare-up following surgery once again resulting in vision impairment, right leg weakness and severe fatigue. She misses a combined 63 days of work resulting from the surgery and postsurgical complications. Thereafter, the complications seem to resolve, and Katie feels that her MS is controlled on the interferon beta-1b. She continues to maintain telephonic communication with her MS-nurse consultant, and visits her neurologist on a regular basis.
Approximately 3 years later in an annual exam, Katie confides to her MS specialist that she is having difficulty controlling her bladder, a common symptom of MS. She is referred to a urologist who prescribes tolterodine (4 mg) twice a day, but recommends a surgical option that he feels will help Katie. Katie undergoes surgery. The surgery is successful, and Katie no longer needs tolterodine. However, she experiences an MS flare-up with weakness in her legs, and is once again placed on high-dose steroids. The steroids eventually help with the flare-up, but her potassium level drops so low she can barely walk to the bathroom. Katie misses a combined 8 weeks of work.
Over the subsequent 12 months, Katie’s MS is fairly stable. There is residual and intermittent right leg weakness along with blurred vision. Her fatigue is at times debilitating and she is noticing some cognitive issues. Her MS specialist prescribes modafinil. Katie remains on interferon and works with the EAP through her employer to modify her work schedule. She is able to set up a telecommuting arrangement to remain at home 3 days a week, commuting to work 2 days a week on Monday and Friday. This schedule provides Katie with sufficient buffer days between her commuting days, allowing her to conserve energy and maintain optimal wellness. Through these employer accommodations, Katie is able to maintain gainful employment and ongoing self-sufficiency.
The Role of the Care Coordination Team
Katie was able to receive appropriate care once she was evaluated and treated by an MS specialist. However, Katie’s symptoms may have been better controlled, and costly, risky hospitalizations may have been avoided with proactive interventions by a case manager. A health plan-sponsored case manager could have identified a plan of care which would have included the following treatment goals:
• Control relapse
• Delay disability
• Reverse disability (future)
• Alleviate symptoms
• Improve quality of life
• Control costs
A health plan-sponsored case manager could have provided many important aspects of care coordination for Katie. These would include:
• Serving as the patient’s primary link to critical information and resources
• Serving as the patient’s primary advocate within complex medical system
• Working with the MS neurologist to develop patient-specific goals
• Being knowledgeable about the various drug therapies being used to treat MS
• Consulting with the pharmacist
• Making arrangements with the PBM for home delivery of medications
• Teaching and reinforcing with the patient how to self-inject
• Teaching the patient how to manage interferon reactions, such as taking ibuprofen starting the day before the injection, icing down the injection site, rotating the injection site, etc
• Making arrangements for lab tests during drug therapy
• Following up with the patient to make sure injections are going smoothly
• Providing a link to the National MS Society and its local chapters, particularly for patients newly diagnosed
• Helping the patient manage MS symptoms
• Being available for telephonic consultations – MS patients have lots of questions!
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