Aetna: Case managers are 'cornerstone' of medical management


Can your company boast a program that leads to positive feedback from your members, plus saves money and improves quality to boot? Aetna can. Its case management program involves trained nurse case managers offering free service and support, helping members manage their benefits, arrange care and find resources. And it has brought down costs, primarily through reduced hospitalizations and emergency room use. In fact, Aetna's case managers can save from $2 to more than $9 per member per month.

To learn more about Aetna's case management services, which incidentally, is the subject of a session at the AHIP Institute today, FierceHealthPayer spoke with Susan Kosman (pictured), Aetna's chief nursing officer.

FierceHealthPayer: What kind of benefits do case managers provide Aetna members?

Susan Kosman: We see it as a cornerstone to our medical management component. There are always going to be cases where individuals need additional help and connection, and we have a wide breadth of medical knowledge and clinical acumen on our team, as well as an understanding of providers in the local markets and programs available to our members.

When thinking about the individuals who use case management services, most don't know what's in an insurance plan until they need to use it. And if they've just gotten a diagnosis, maybe received multiple prescriptions or had visits with several providers, it's really helpful when they can have someone as a trust advisor to help them figure out how to link services they're trying to access with their specific benefits.

Case managers really help in reaching out to members who can use education, whether about the diagnosis or benefit plan, as well as navigating the system to help them understand available providers or their care regimen.

Case managers also help members understand how that diagnosis or healthcare event fits into their life. A diagnosis is only part of a member's life; how does it fit into their personal identity or family situations that may present their own challenges, for example. So the case managers really work on the member's terms because they're often dealing with some other level of emotion alongside the diagnosis or acute event.

FHP: How does Aetna alert its members to these case management services?

Kosman: There's a couple of ways that happens. Oftentimes with enrollment there will be materials about the availability of our case management program. But like most insurance, sometimes you don't know what you have until you need to use it. So we do outreach based on triggers, including when members access certain types of care or services like filling a certain prescription, that would prompt a case manager to reach out to that member, explaining that because you got this prescription filled, there might be other programs that could be helpful while also ensuring they understand their benefits.

Making people more aware of the case management program is going to become more important when the health insurance exchanges open. There's so much information in healthcare today, so case managers and their multi-disciplinary approach are really important to helping members understand how to become in charge of their own health and their own care, which is sometimes a daunting task. 

FHP: Do you have any results that can be attributed to the program?

Kosman: There are a couple of metrics we look at and they do differ a bit based on the program that an employer has implemented. But the things we look at from a cost perspective are utilization, readmissions, reduced ER visits, overall decreased days in facilities. Then there's clinical metrics, including ideas around a specific disease category. For example, ensuring that a member with diabetes is receiving appropriate testing.