4-page Case Study - Posted 3/30/2006

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Premera Blue Cross

Leading Healthcare Insurer Avoids $9.6 Million in Costs with Case Management Tool

At Premera Blue Cross, an independent licensee of the Blue Cross Blue Shield Association, case managers handle the post-hospitalization needs of patients with complex medical conditions. Until recently, opening a new case could take 160 minutes and require using two different case management systems. Ongoing management was paper-intensive. Working with Microsoft and Microsoft® Certified Partner Accenture, Premera built its Case Management Collaboration Tool using Microsoft Office Professional Edition 2003, Microsoft Office SharePoint® Portal Server 2003, and the Microsoft Office InfoPath® 2003 information gathering program. The new tool shaved 40 minutes off the time to open new cases, reduced research time by 70 percent, increased case capacity by 20 percent, and improved employee satisfaction by 17 percent. Premera estimates that the annual medical cost savings from deploying the Microsoft solution will be at least U.S.$9.6 million.

Situation

Operating as Premera Blue Cross in Washington, and as Premera Blue Cross Blue Shield of Alaska in Alaska, Premera serves more than a million members through a large, diverse network of providers—nearly 18,000 healthcare professionals and 100 hospitals in Washington, and 840 professionals and 23 hospitals in Alaska. As part of its services, Premera employs professional case managers to coordinate the treatment that seriously ill or injured patients receive after they leave the hospital. For instance, a patient who was in an automobile accident might have not only fractures, but also internal injuries and even closed head trauma. The patient with those injuries will be seen by multiple physicians both in the hospital and after he or she is discharged. The case managers, who are primarily registered nurses (RNs) and social workers (MSWs), coordinate that treatment after a patient’s hospital stay. 
 

Before we had the tool, I found it difficult to manage the 30 patients I covered in a timely manner. Now I am managing between 40 and 45. Jan Hudson, RN, Case Manager, Premera Blue Cross

Each case manager was handling about 30 member cases at a time; all together, the team managed more than 8,000 cases a year. In complex cases, each patient might be working with five different physicians or therapists. In addition to working with those direct care providers, case managers had to track lab tests, medical equipment, and pharmacy orders, and conduct post-release planning that factored in family support or lack of it. It is complex work.
 
In healthcare, complexity can be expensive, not to mention dangerous to a patient if different treatments overlap, leave gaps, or conflict. Just making sure the right tests are done in the right order can save money, plus patient time.

“Case management has three goals,” says Dr. Castiglia: “to provide peace of mind to members by managing a comprehensive plan for their health needs; to provide the information that consumers, employers, and providers expect in this era of consumerism; and to respond to the concerns caused by double-digit increases in insurance premiums. Premera provides care management, plus information about the cost of that care and its quality.”

“We’ve learned through the past few years that case management is one way to help control costs,” explains Linda Coulson, RN, BSN, and Director of Care Management at Premera. Expanding case management to reach more members would help members get higher quality care, which often helps lower overall costs. For instance, case managers who learn of patients’ chronic conditions or post-operative complications can arrange treatment that avoids readmission or additional surgery.

Premera case managers, hampered by an outdated IT infrastructure that was never designed for cross-disciplinary case management, were organizing their work on paper, often using large numbers of multicolored sticky notes on their desks and computers—certainly not a convenient or efficient way to work. If a case manager was unfamiliar with a condition, she or he would research it independently and store the results on a personal computer; colleagues had no way to search across all the illnesses that team members had already investigated, so they often wasted time duplicating efforts.

Solution

Working with Microsoft, Microsoft® Gold Certified Partner Accenture, and the Premera IT department, Premera case managers specified the Case Management Collaboration Tool, which has about 20 tasks to help nurses follow and meet URAC standards. URAC is a national organization recognized as the authority in setting high standards for health-care programs. 

Case managers now work with Microsoft Office SharePoint® Portal Server 2003, which lets them view their cases in detail and the tasks associated with each patient. The information is stored in a Microsoft SQL Server™ 2000 database dedicated to care management. As the care managers work on a case, they use an electronic form created in the Microsoft Office InfoPath® 2003 information gathering program that collects information on the status of various tasks and gives reminders to help guide the case manager through the process flow. Training case managers to use the tool takes no more than one or two hours, since the tool uses the familiar Microsoft Windows® operating system and Microsoft Office interfaces.

Case Tool Floe Diagram

Explains Castiglia, “Through this tool, the nurse has contact information for each member receiving treatment. Case managers easily track action items to follow up on the different orders that physicians have written and make sure that there are no conflicts between the different orders. The case managers can also educate the members on what is happening. Many times, members will go along with a physician’s order, but they won’t really understand the implications. With this, the nurse can act as a resource and help the member make better choices.”

For the nurses at Premera, collaborating with Microsoft proved a pleasant surprise. “They were great to work with,” says Coulson. “We’re not technical people, but they had great suggestions, and they listened to us when we had suggestions. Microsoft took the time to learn what our case managers did and to understand the process.”

The company rolled out a pilot with about nine case managers, then expanded it to the entire group of case managers because it proved so successful. Key to the popularity of the tool is the fact that end users helped to formulate the requirements, and they can extend it to meet their personal style of working.

“Although we have a set task list,” says Coulson, “the case managers can set action items and sort them by date, and they also have a flag that they can put on a particular task so that each day, when they come into work, they’re able to see what their top priorities are.”

Premera has also replaced its old claims administration systems, which were running on a mix of five mainframe and mid-range systems, with Facets administrative software from TriZetto on a Unisys ES7000 running the Microsoft Windows ServerTM operating system and a SQL Server database that case managers interact with for research and billing. The new claims administration system is more agile and efficient, and it interfaces easily with the Case Management Collabora-tion Tool. Now, the case management tool receives updated case information from Facets twice daily; Facets also provides case management nurses with a view of each patient’s claims history. Without involving the Premera IT department, care facilitation business analysts can generate special reports from the Case Management Collaboration Tool’s SQL Server database.

Benefits

By pulling together much of the information that case managers need and providing links to other resources, the collaboration tool provides a quick, easy-to-understand view into a complex workload. As a result, case managers have been able to give more consistent information to Premera’s members and help ensure that they learn about quality organizations in their community for excellent care.

The tool has increased job satisfaction and efficiency so much that Dr. Castiglia says it could be worth U.S.$9.6 million a year. “From what we’ve been able to see so far, with a 20 percent increase in efficiency, that means our 56 nurses are really acting as 68 nurses. It gives us about 12 more nurse full-time equivalents in terms of efficiency. And we figure that each nurse is worth, in terms of decreasing medical costs, U.S.$800,000 to $900,000 a year in the complex case environment. The total would be 800,000 times 12, or about $9.6 million dollars a year.”

25 Percent Increase in Overall Operational Efficiency

The most dramatic impact has been on time to open a new case, which dropped from 160 minutes to 120 minutes. With the new tool, simple tasks are automatic (the case tool is pre-populated with a member’s information), and complex tasks are made easier, because the tool provides soft links to reference material about the member’s case history. So, instead of going to six or eight locations, managers just click through the tool. Time saved on inputting data and hunting for information can go into more patient care.

Previously, each case manager collected a patient’s information using many different methods, and when one manager’s caseload began to become overwhelming, it was difficult for a co-worker to lend assistance, because each manager’s workflow was distinct. With a consistent workflow, when cases are re-assigned to a different case manager, the convenient task list readily shows the next actions. 

We’re not technical people, but they had great suggestions, and they listened to us when we had suggestions. Microsoft took the time to learn what our case managers did and to understand the process. Linda Coulson, RN, BSN, Director of Care Management, Premera Blue Cross

“What I like about the new tool,” says Hudson, “is it gives me all my members in one screen shot, and it tells me what I have to do as my next action. I put in little reminders for myself, so I don’t have to go back and process as much of the charting information. The system tells me when I have completed a certain task and lets me put in what I think the next step should be.”

Better Tools Mean Better Care

For the individual case manager, the tool organizes the complexity of the workload and offers a way to set priorities in the day. For example, when Premera’s pool of members expanded, Hudson took on 40 new complex cases and had their case management programs up and running in two weeks— before the clients themselves had even transferred over to Premera. “I don’t think I could have done that before.” 

Coulson, the director of care management, estimates the transfer would have taken at least five to seven weeks with the old process. “These were members with catastrophic conditions,” she added. “This ensured there would be no break in care. Even before they came into our plan, we let them know we would be here for them, and gave them some peace of mind that we would help them find the right providers and would continue coordinating the care with their physicians.”

Case Manager Job Satisfaction Up 17 Percent

The new approach to case management has made the work more satisfying, because professionals who are spending less time on simple tracking can spend more time on patient care.

“Before we had the collaboration tool, case managers would have to go in and out of multiple databases and multiple programs,” says Coulson. “It was very time-consuming paperwork, and they were feeling very frustrated that they didn’t have an efficient task manager. After using the collaboration tool, we did a survey of our case managers, and their satisfaction increased by more than 17 percent.”

Expanded Management Capacity Worth $9.6 Million

Premera’s IT department is also pleased with the case management and the new core processing system that supports it. “One of the exciting outcomes for me with the care management collaboration project was how quickly we were able to put a tool together using the Microsoft .NET Framework, Office Professional Enterprise Edition 2003, and InfoPath 2003,” says Dave Young, Vice President of IT Applications for Premera. “We developed an application for one of our internal business departments and almost immediately started realizing a return on investment (ROI). In the mainframe environment, it would take months to put together a similar product, and months after that to see ROI.”

The collaboration tool has greatly enhanced employee efficiency and satisfaction, and the expanded case management capabilities have saved Premera an estimated U.S.$9.6 million a year in medical outlays on the management of complex cases.

The work described in this document was previously performed by professionals who were part of a practice that Accenture acquired in 2005.

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