Tangible care management

While Medicare is not exactly known for its capacity to manage the health of its members, an expired pilot project has provided the springboard for a commercial insurer to grow its care management abilities.

In 2005, a limited liability corporation called Green Ribbon Health (GRH), which was formed by a joint venture between Humana and Pfizer, won a bid to provide care management support to 24,000 Medicare members in a pilot project. That project ended in 2008, and Humana acquired GRH, hoping to leverage the progress it had already made.

Under the pilot, members were randomly assigned for GRH support, but many were too sick to be impactable, Bisio says. Some were at an end stage in a nursing home, for example. Others, however, were healthy enough to golf seven days a week and were confused as to why they were connected to care support.

"They wanted to know why we were calling them," she says. "We needed to figure out a better way to identify people who really need this level of intervention."

Chronic care management is not an inexpensive proposition, she says, so identification of impactable members became a key focus of the GRH pilot.

Double the impact

Today, Humana Cares has expanded the structure of the former GRH platform to a national reach, offering complex care management to 75,000 members. In less than two years under Humana, the division recorded a 36% decline in hospital admissions and a 22% decline in emergency room visits among participants.

Last month, it announced that it is adding a new chronic condition management program, serving an additional 60,000 commercial plan members and hiring 270 new associates in the process, bringing the employee total up to nearly 800 people.

"Humana has built us from service in one state, both in the field and on the phone, to 50 states on the phone and 30 in the field," Bisio says. "That's a huge commitment to infrastructure."

Humana Cares offers:

The nurse care managers are exclusive to their specific caseload of members and average 19 years of experience. Field workers and nurses aren't tethered to a call center or worksite, Bisio says. Each works in the area of service, often connecting with members at the member's convenience.

Humana Cares has also added remote home monitoring to its quiver to enhance telephone interaction through live video so care managers can see members, ensuring a comfort level but also to assess visual cues such as weakness or possible depression.

"We're giving them somebody who's going to be there and is objective," Bisio says. "If you've ever experienced having to take care of an ill parent or relative, you lose your objectivity. You get so emotionally involved in it."

She says the new addition of the chronic care management program goes beyond traditional disease management in that members will have access to field care managers and educators as well as their own dedicated telephonic care manager.

And there's great potential for the new service to round out acute and routine provider care. Bisio notes that 38% of Medicare members have three or more chronic conditions, and 73% of those over the age of 65 have more than one chronic condition. Chronic illness has an economic impact of $1.3 trillion annually in the United States, with an expected increase in disease prevalence of 40% by 2023.