At Blue Cross Blue Shield of Minnesota, a Care Management Program with Major Results

A program that’s been underway for a few years now at the Eagan, Minn.-based Blue Cross Blue Shield of Minnesota, called the High Complexity Case Unit (HCCU), is showing real results.

As explained in a blog posted on the BCBSMN website on Dec. 12, 2018, some health plan members/patients require both medical and social services from a wide variety of providers and caregivers. To better address the serious challenges and high costs associated with caring for these patients, Blue Cross launched the HCCU program in September 2016. The program has been growing ever since, helping to make health care more sustainable one case at a time.

"The goal of the HCCU program is to provide patient-centric care management that works to deliver better outcomes and experiences for our members at a lower overall cost," Dana Erickson, R.N., then vice president of care management at BCBSMN, said in December 2018, in the blog. Erickson’s current title is senior vice president, health services.

As the blog noted, “Through the analysis of a member's medical history, previous claims and ongoing treatment plans, the HCCU team can identify opportunities to streamline care and improve a member's health holistically. Typically, members engaged in HCCU are dealing with multiple diagnoses and complications, creating a very confusing and expensive scenario.  By taking a step back to address the situation and work with health care providers across various specialties, HCCU helps to ensure that the appropriate coordination of care plan is in place for each member.”

"Even on a good day, the health care system can be very difficult to navigate," Erickson said in December 2018. "HCCU was designed to identify the most complex situations and provide one-on-one coordination across all aspects of care for that individual.” And, the blog noted, “The one-on-one approach is proving to work. Members with complex health conditions are getting the best possible care through their trusted coaching relationship they develop with their health coach.”

The blog also quoted Marcy, one of the registered nurses working in the HCCU. "We work with members on a deeper level," Marcy said. "The most rewarding part of the job is the relationships I build with members."

Recently, Healthcare Innovation Editor-in-Chief Mark Hagland interviewed Erickson and Mark Steffen, chief medical officer at Blue Cross Blue Shield of Minnesota, regarding the successes that have been logged by the HCCU program, and the implications of those successes for the broader healthcare field. Below are excerpts from that interview.

Tell me about the origins and evolution of this very successful initiative:

Mark Steffen, M.D.: When we looked at this, it was confirmed for us, not surprisingly, that it’s a small percentage of the population that utilizes a majority of the healthcare resources. We’re increasingly recognizing the improvements we can make from the care coordination and care management standpoint. We can make the care more effective for our members, and deliver better health outcomes, but we need to support our members through that journey, because the healthcare system is extremely complex, and they may not always be seen by individuals who have a holistic view of the member. So when we looked at some of these complex members, we started thinking through how to help them.

So the high-complexity case unit was designed to create a cross-functional team, just as you’d see in any integrated delivery system, to manage those members. We had nurses, pharmacists, medical directors, all collaborating and looking at some of the complex needs, and at their medical record, and looking at what they need, not just purely from a medical standpoint, but also their social needs.

So you really are incorporating the social determinants of health in this?

Yes, absolutely, our nurse case managers are absolutely empowered to ask those questions. At Blue Cross Blue Shield of Minnesota, we’re looking to address those social determinants in a substantial way, per costs and outcomes.

How many members are in BCBSMN, and how many in this universe?

We have just under 3 million plan members overall. And if we looked at, say, from January through September in 2018, those high-complexity case unit nurses connected with about 900 members.

So, a regular load of about 1,000?

Yes, that’s January-September numbers, so annualizing those, it’s over 1,000.

Do you have an overall estimate of the number of plan members touched by the program?

If we’re looking at 2019 as an entire year, knowing we had 1,400 members engaged, then it’s been about 1,500 this year. And it’s more than doubled in 2019 compared to 2017.

What does this population look like clinically?

It’s a combination of individuals with complex chronic diseases and who have acute-care needs—either one that developed out of a chronic condition, or think of cancer, where there’s a very intense period where someone needs complex treatment; so it varies between those two groups. They’re typically engaging with multiple types of care delivery systems and specialties, and need help with both the medical system and supports in the home, such as care in the home, transportation, food needs. So they’re looking at that holistic spectrum of care required; and it’s generally a complex picture when you look at the typical member. But the conditions vary.

So the majority are chronic rather than acute, correct?

It would be fair to say that the majority are individuals with chronic conditions, but also likely to have some type of acute condition exacerbating their chronic condition.

What have been the biggest clinical, care management, and operational challenges in working with this population in this program?

Dana Erickson, R.N.: The biggest operational challenge is always, in these programs, engagement with members and with providers. Imagine a family member getting a reach-out from their insurance company, asking to engage with them to help them, sometimes there’s an inherent distrust. Now, Blue Cross generally has a good reputation in terms of caring for our community. And we pretty quickly get over any mistrust; but just getting to our members and getting them engaged in the program.

Steffen: Clinically, a lot of this is the variability in the healthcare system, depending on where the member might be. Navigating systems can be extremely complex, even for people who know the systems well and know how they function. So the care managers are engaging the members and explaining what type of support they’ll be getting from the care team.

Erickson: And all of the social aspects. Clinically, our nurses and doctors know how to navigate; it’s not that it’s not clear from the standpoint of a clinical pathway; but a lot of it has to do with the SDOH. Our nurses spend a lot of time focusing on the social aspects, actually, almost like pseudo-social workers—food, transportation, etc.

Steffen: Yes, and it’s even harder to identify some of the community supports that exist for the social determinants of health.

Can you share specifically about a few advances you’ve made?

Erickson: The first thing we recognized was the need to work very, very closely with providers; so very early on, we recognized the need to work as closely with the providers as with the members, and offering them information on cost savings on medication that could save patients money, for example. That turned out to be an early key to the success of the program, along with adding the behavioral resources and social supports. They found early on that so many of the barriers were social.

And how would you describe from your perspective what these plan members look like?

Many of them are chronic in nature, with multi-chronicity; rarely do you see someone with just one issue. The other thing we’ve seen is high ER utilization, due to social aspects. High utilizers in general tend to show up. We can dramatically and quickly show success. We had one patient with 17 ED visits in three months. They were very poorly controlled, didn’t have a good connection with a physician. 17 ED visits in three months is astronomical by any standard. And making sure they have the right physician. In that case, it wasn’t even that. The case manager identified the correct physician. But once you’ve got a good physician provider with a good system, great. Being a nurse, I’m sitting next to a physician here—the relationship between the provider and patient is the most important. And sometimes, we have to help them find a different provider.

Steffen: Yes, the care managers act as advocates for the patients, the members. The member may not have realized they weren’t connected to the right physician. We connect them up.

What data analytics and IT supports have been involved?

Steffen: We do have identification algorithms, to help us prospectively identify the members whom we should be reaching out to. It’s a high-touch program and we have limited resources; we can’t reach every ember, so we want to reach those who will benefit  from the HCCU. And we analyze in retrospect. Members enrolled in the program begin with an average annual medical spend of $220,020 prior to engagement. This stat is in relation to the $24,940 reduction in total medical spend per engaged member per year. Both pieces of information are based on internal claims data analysis.

Erickson: And this group has shown a 6-percent reduction in readmissions, which is pretty significant.

Steffen: When you translate those numbers, I think it’s important to realize what that means to people. For every one of those individuals who didn’t have to spend a night in a hospital and get exposed to hospital-derived infections, etc., it’s major.

What will things look like in the next few years, as the program moves forward?

Steffen: We’ve seen continued growth of this team. We’ll continue to grow it in a reasonable fashion. We’d love to touch every member, but we need to identify those who need it the most.

Erickson: We are looking at disease states. We started out hiring a couple of oncology-expert RNs. We showed some pretty good outcomes, but also the ability to partner with our providers in these specialty areas. Transplant and renal disease are two areas we’re looking to expand into, and a third, cardiology. Where we bring in a condition-specific clinical group, and bring in some pathways for them.

What would your advice by for CIOs and CMIOs of any organization that would look to develop a program like this?

Steffen: I think that identification is absolutely important. We’ll never be able to do as much as we’d like, from an analytics perspective. We’d love to be able to identify these individuals before they become high-cost members; so the further we can take analytics in a predictive direction, the better. That will be an important part of the journey from a CMIO perspective; and then refinement, looking at those specific populations, so that we can be more impactful and get them with the right experts at the right time.

Erickson: It’s been on my wish list for years: how do we use technology to connect more fully with our members? We use claims primarily, and claims are old. Everybody’s saying this, right? How do we become more connected with providers and with clinical data, so that we can engage at the impactable moment? Data sharing—and how we can engage initially. We’ve been primarily focusing on telephonic outreach at the beginning, and then the use of text and other technologies. And there are still understandably a lot of privacy concerns, and people have to have comfort. But the quicker we can get there, the better, in terms of engaging on a daily basis.