It’s easy to think of health insurers as just the folks who collect premiums and pay bills. But a good health plan can do much more: Not only can it control costs by ensuring dollars are spent wisely, but it can help members coordinate their care and better manage their own health.
At Blue Cross & Blue Shield of Rhode Island, those functions are led by Dr. Harold A. Picken, vice president of health operations. Picken answered questions about his team’s work.
PBN: You oversee health operations. Can you explain what that is?
PICKEN: It includes case management, disease management and utilization management, which are all included in our health plans at no additional costs. We work closely with our members with the most serious illnesses or who are dealing with chronic conditions such as diabetes, heart disease, asthma and chronic obstructive pulmonary disorder. The key is to help them manage their conditions to improve their health and avoid complications. We also work closely with our Health & Wellness Institute, our wholly-owned subsidiary, which provides wellness and screening services at work sites, by phone and by mail.
PBN: What does case management entail, and how do you determine who requires it?
PICKEN: Our case management team of nurses and social workers work with our members who are facing cancer, transplants, strokes, brain injury, and other serious health challenges. Depending on the situation, they may help a member find services and support during transitions from the hospital to home. They may also help that member follow a treatment plan and/or find community resources that can help. Eligible members can choose whether to participate in case management, and the same is true for disease management.
PBN: What does disease management entail, and how might it help, say, a diabetic?
PICKEN: Disease management helps members with chronic conditions. Over the telephone, our nurses provide education and monitoring to members with conditions such as asthma, heart failure and diabetes. We believe that many exacerbations of chronic conditions can be avoided by focusing more resources on patient education and monitoring.
With a diabetic, we start by discussing with them how they’re managing their condition. Then we ensure they are taking their medications properly. … Next, we provide education about their illness, ensuring they understand how critical it is to monitor for high blood pressure and high blood cholesterol or lipids. We teach them to “know your numbers” – their blood pressure and lipid levels, not to mention hemoglobin A1c – because we believe that makes them more likely to take ownership of their health. …
Historically, health plans have provided support to members without much involvement from the person’s doctors. That’s now changing, so everyone – BCBSRI, the patient, their physician – is moving in the same direction.
PBN: How does utilization management work these days, and how do you strike a balance between appropriate utilization and appropriate cost containment?
PICKEN: Utilization management addresses the widespread overuse of certain medical therapies. It helps determine whether available medical evidence supports or doesn’t support a test or treatment. We want to help our members get the right care for their unique needs. …
The most common situation that requires utilization management is one in which a new technology is proven useful for some patients in specific situations. All too often, it will be recommended to a broader set of patients than for whom there is supportive medical evidence.
As a health plan, BCBSRI is also a steward for the quality and cost of health care for the members and employers who pay for it. We have an obligation to pursue available methods to limit expenditures and undetermined risks to our members from unproven care.
PBN: What do you find most challenging, and what do you consider to be your biggest successes?
PICKEN: As a health plan, we have access to information that describes the evidence in support of different medical diagnoses and therapies, and we have in-house physicians and other medical professionals who understand that information. We have an obligation to help our members pursue affordable, high-quality health care and not simply process claims. We are committed to improving the health of our members. That’s our greatest challenge. …
Our biggest successes come every time a member calls to thank us because they quit smoking, survived breast cancer, or experienced some other major health improvement and feel we had a role in that. … Study after study proves that people who quit smoking, exercise, eat right, maintain a healthy weight, and so on, reduce their risk for a host of chronic conditions and diseases. These diseases not only weigh heavily in terms of health care costs, but also place an immeasurable burden on a person’s and their family’s quality of life. So these successes inspire me and everyone I work with to help other people make similar changes.
