Reinsurance for Early Retirees Program

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1 Summary of Programs Disease Management CareFirst's approach to disease management seeks better management of members diagnosed with certain high frequency, high cost diseases through the early detection of chronic conditions. We define disease management as a comprehensive, integrated, and targeted approach to care for members with selected chronic or life-threatening diseases. We help members who have certain diseases to monitor and manage their health so they can make smart choices for healthy living. Core conditions (Package A) and impact conditions (Package B) are covered as part of the standard disease management offering for fully insured groups. Self-insured groups are charged an additional fee for the disease management programs. Disease management program options are as follows: Package A Core Conditions Asthma Diabetes Congestive Heart Failure (CHF) Coronary Artery Disease (CAD) Chronic Obstructive Pulmonary Disease (COPD) Package B Impact Conditions, plus Package A Low Back Pain Osteoporosis Osteoarthritis Hepatitis C Urinary Incontinence Decubitus Ulcers Atrial Fibrillation Inflammatory Bowel Disease Irritable Bowel Syndrome Fibromyalgia Acid Related Disorders Package C Other Conditions*, plus Packages A and B End Stage Renal Disease (ESRD) and Chronic Kidney Disease (CKD) Chronic Kidney Disease (CKD) Comprehensive Back Pain (CBP) Depression *Listed conditions (ESRD, CKD, CBP, and depression) can be purchased and added à la carte to Package A or B. End Stage Renal Disease (ESRD) can only be added to Packages along with CKD. Identification Members are identified for participation in the programs primarily through clinical analysis of medical and pharmacy claims data. Comprehensive data feeds on a timely basis are critical to working with this population. 1 CareFirst BlueCross BlueShield

2 Claims data feeds are refreshed on a monthly basis and algorithms are applied to continue identifying new disease management candidates. Other sources of identification include providers, self-referral, family member referral, the utilization management process, and a health risk assessment tool, if appropriate. Once identified members are stratified into different levels based on risk of future high cost using predictive modeling. CareFirst has long recognized that pharmacy claims are needed to administer the DM program. If a group has a third-party PBM, the sales representative works with the employer group to arrange for a contact for pharmacy claims files to be sent to CareFirst. A CareFirst IT representative then works directly with the PBM s technical support to format the files and arrange for monthly downloads. A signed business agreement is required allowing the PBM to send CareFirst the pharmacy data monthly plus three years of historical pharmacy claims data. Stratification Stratification is a process that identifies high-risk/high-cost members and stratifies them into risk categories for the purpose of providing the appropriate level of interventions at the right time. Members are assigned to one of four stratification levels. The higher a member s stratification level, the greater the frequency of engagement and intensity of the intervention. Members are contacted either by telephone or by mail depending upon the component (e.g., clinical assessment, depression screening, self care goals). We generally define the four levels of stratification as: Level 1 Participants that are stable and at lowest risk for utilization or exacerbation of their condition. Level 2 Participants who are at some risk for utilization or exacerbation of their condition. Level 3 Participants who represent moderate risk for utilization or exacerbation of their condition however still preventable. Level 4 Participants at highest risk for utilization or exacerbation of their condition and timely action is required to mitigate risks. We utilize a four tier stratification process to provide members with the appropriate resources at the appropriate time and frequency. Stratification is a fluid process and participants are continuously re-stratified as changes are identified via claims data, provider feedback, clinical status changes, or behavioral assessments. Level 1 participants are stable and at the lowest risk for utilization or exacerbation of their condition. Members in this level are participatory in their plan of care and receive the least intense interventions. Level 2 participants are at some risk for utilization or exacerbation of their condition. Most members initially enter the program at a level two stratification and are then re-stratified based on clinical assessment responses, provider feedback, clinical judgment and physical or behavioral changes as reported by the member. Level 3 participants have a moderate risk for utilization or exacerbation of their condition; however these are still preventable. Level 4 participants are at the highest risk for utilization or exacerbation of their condition and timely action is required to mitigate risks. Members in Level 4, the highest risk/severity, require the most intense interventions. Level 1 (lowest risk) members receive the following interventions: welcome packet, welcome call, triage assessment, standard of care reminders, and condition specific newsletters. Members identified as levels two, three, or four receive the following interventions: welcome packet, welcome call, clinical assessment, scheduled care calls, interventions, depression screening, medication review, standard of care reminders, satisfaction survey, self-care goals, educational materials, disease specific newsletters, and health perception measurement. All members have access to a disease management website and toll-free support line. 2 CareFirst BlueCross BlueShield

3 Case Management Case management is an integral component of the care management process. Coordinating continuity of care, including catastrophic/chronic care, can be challenging to members and families who are unaccustomed to health care delivery systems. Case managers work directly with providers, members and their families to identify specific health care needs of the member. The case managers are responsible for developing an individualized care plan with short term and long term goals that are agreeable to all parties and medically appropriate. Once case management services begin, the case manager monitors the progress of the care plan and makes any necessary changes to the plan of care to maximize optimal outcomes. The case managers may provide community resources, education and other self care recommendations. Case Management services are provided by licensed nurses (e.g., RNs) and are based on caseload, acuity, and specialty (e.g., oncology, rehabilitation, high-risk and healthy pregnancy, pediatrics, multiple trauma, etc.). Once a member is assigned to a case manager, the case manager continues to work with the member until the issues or needs are resolved. We utilize multi-disciplinary treatment teams for ongoing case management of specific diseases or conditions. Case Management consists of the following processes: Comprehensive assessment the collection of in-depth information regarding a member s health care needs and situation Planning the process of determining specific objectives, goals and actions designed to meet the member s needs as identified in the assessment process Implementation carrying out the interventions identified in the care plan to accomplish goals and positive outcomes for the member Monitoring the ongoing process to determine the plan s effectiveness and make appropriate changes as necessary Continuity provide ongoing health education and community resources. The goal is to support the member/family in moving toward self-care and independence. Evaluation to determine the case management plan s effectiveness in reaching desired outcomes/goals Outcomes to identify and implement changes in the plan of care to produce results that are positive, measurable and goal-oriented Care that is coordinated through the case management processes may include outpatient and/or inpatient services; a member does not need to require a hospital level of care to be eligible for case management. CareFirst recognizes that well managed, alternative care settings may be beneficial for continuing care of chronic and catastrophic illnesses and medical management of short-term illnesses. CareFirst has established a network of alternative care providers including home care, hospice, and infusion therapy. Case management is a voluntary program. Members are identified for participation through various sources, which include providers, self-referral, family member referral, utilization review nurses, pre-certification process, claims reports, and through the use of a "trigger list." During the utilization management process, a utilization review specialist automatically refers a member diagnosed with one of the conditions found on the "trigger list" to case management for evaluation. Utilization review specialists may also refer members who are diagnosed with conditions not found on the "trigger list." These members may be targeted for case management evaluation because of frequent readmissions or special 3 CareFirst BlueCross BlueShield

4 circumstances (e.g., lack of family/social support that is needed to ensure the safe care for the member) not appropriate for the utilization review specialist to coordinate. Programmed within CareFirst s authorization software application is an auto-routing feature of ICD-9 codes that are appropriate for case management referrals. Any time an authorization is created with the appropriate ICD-9 code, it is routed automatically into the case management intake work queue. The following is a list of diagnoses/conditions that identify the member as a potential candidate for case management services: Terminally Ill HIV/AIDS All Cancer Patients ALS End Stage COPD All Hospice Referrals Great Beginnings All Pregnant Women High Risk OB Multiple Gestation Pre-term Labor Substance Abuse Pregnancy Induced Hypertension All Teen Pregnancies Possible Termination All Gestational Diabetics Members who present for pre-natal care late in pregnancy or are non-compliant with same Rehabilitation Intracranial Bleeding Anoxic Encephalopathy Multiple Trauma CVA Head Trauma Spinal Cord Injury Neurological Degenerative Disorders Guillian Barre Multiple Sclerosis Physical Disability Developmental Disability Chronic Illness Asthma CHF Diabetes 4 CareFirst BlueCross BlueShield

5 Lupus Any Chronic Disease Pediatrics Prematurity Respiratory Distress Syndrome Cerebral Palsy Cystic Fibrosis Failure To Thrive Feeding Disorders ALL NICU Admissions Asthma Congenital Anomalies Children with special health care needs (less than 17 years of age) regardless of marital status, suffering from a moderate to severe chronic condition with significant potential impact on health and ability to function Any infant identified through screening who was admitted to a Neonatal Intensive Care Unit (NICU) or special care nursery at the time of delivery. (Note: if this is identified by a Great Beginnings Case Manager, an is generated with infant s name, diagnosis, and membership number to the Pediatric Supervisor.) Psychosocial Stressors Family/Social support inadequate to provide safe care History of family violence/abuse or medical neglect Adjustment to illness/terminal illness Homelessness Need for complex coordination of community services This list is meant to serve an inclusive rather than exclusive function. When special circumstances exist, the case manager screens the referral and determines if the member is accepted into case management. High-Intensity Case Notification Case Management cases are not routinely identified through the claims payment process; however, during an audit of high dollar claims review, a claims examiner may note a potential candidate for case management services and make the appropriate referral to case management. Case Management takes a proactive approach to identifying members before high cost claims are incurred. CareFirst s Medical Informatics Department has developed the High-Intensity Case Notification (HCN) system. HCN uses data from a variety of sources to identify patients who have been authorized for services and may incur large claims expenses (greater than $50,000) in the near future. Self-insured accounts get a one page summary report twice a month for all conditions identified for their members. The same information is shared with our case mangers to be certain that the members are receiving case management services. Reported conditions include: Gastric Bypass Transplants Hospital Admission for Trauma Hospital Admission for Burns Admission to a Neonatal Intensive Care Unit 5 CareFirst BlueCross BlueShield

6 Case Management Closure Once a member s identified healthcare needs/issues are resolved, the case manager documents the termination and notifies the member and the provider that case management services are terminated. This closure notification is documented in the chart, as well as the reason why a case is closed to case management. 6 CareFirst BlueCross BlueShield

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