Aetna: Case managers are 'cornerstone' of medical management
FHP: Can you describe some examples of the types of outreach case managers provide?
Kosman: There are cases that we look at in a few different ways. One way is that you might be making an outreach on a particular type of trigger where you're anticipating that you might be doing some situational education. For example, a member might utilize an emergency room for something that could have been equally handled in an urgent care facility or physician office.
At the outset, you might be making that outreach to explain benefit differentials for utilizing different types of services to help understand why they went to the ER. In some cases, those calls might be a one-time outreach because circumstances were such that in the moment it made sense but now they understand their benefits, they have a primary care provider and they're going to make that connection going forward.
But you could have that same call and find out the member has been utilizing the ER more regularly because they haven't established that primary care connection or they really don't understand the implications of their disease process or the incentives aren't aligned for them to get to the doctor's office instead of the ER. So that call might be equally about educating the member about the benefits, but also may continue to be about helping the member link to a primary care provider and determining whether there are other options in their geographic area so they're not dependent on the ER for routine care.
Case managers might also look to see whether there's an appropriate program to engage the member in to help manage their symptoms so they don't need the ER.
So we do have some cases that may close relatively quickly after a few calls and some where we stay engaged for many months.
FHP: What kind of education and background do your case managers have?
Kosman: We actually have a mix of case managers. The vase majority of them are registered nurses, and many of them have a bachelor's degree. We look for individuals who have at least three to five years [experience working] in a clinical setting because we want individuals who are coming with an understanding of disease process and hands-on care.
But we also have social workers, behavioral health specialists and psychologists. We do find having that mix is really quite valuable in terms of leveraging the clinical expertise and acumen across those disciplines, as well as across clinical settings because we have quite a variety of clinical expertise, from pediatrics, oncology, rehab and pretty much every specialty out there.
FHP: Do you think a case management program like Aetna's will help set the company apart in the evolving consumer-oriented market?
Kosman: When we think about individuals who are going to be on the market in the [health insurance] exchange, they really are a mix of individuals. Case management is going to become even more important than it already is in understanding where a member is to help align them with the right program. Individual members don't really know what they have until they need it, so especially on the exchanges in the absence of benefit managers, case managers are going to play an enhanced role to the member navigating the healthcare system potentially for the first time.
Case managers are uniquely positioned to make that strong connection between helping individuals navigate [insurance choices], as well as assisting them in understanding whatever circumstance or condition brought them to need those services in the first place. They also can help make individuals better consumers to use the tools that are available.Case managers really can be an essential link and a real advocate for members in that space.
Editor's Note: This interview has been condensed and edited for clarity.
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