Blue Cross Case Managers personalize care to improve employee health outcomes

Case Managers play an important role in coordinating members of the clinical team, driving toward the goal of a smooth member experience and positive health outcomes. For employers, this care coordination results in healthier employees and more efficient healthcare spending, especially for employees with chronic health conditions and those at risk for repeated hospital stays.

A healthy workforce saves employers money. Blue Cross and Blue Shield of Minnesota data show that members who participated in our Case Management programs saw up to a 19% trend reduction in medical costs.¹ These savings are determined by measuring program effectiveness, closing care gaps and reducing absenteeism.

The healthcare system can seem complex, fragmented and difficult to navigate, leaving members confused and frustrated. A recent survey found that 61% of Americans say the U.S. healthcare system is a hassle and 53% feel it treats patients more like a number than a person.²

Blue Cross Case Management tackles these challenges, making healthcare more personalized and effective by empowering your employees throughout their healthcare journey. Our trusted approach takes a holistic view for the member, including social drivers of health (SDoH), synchronizing various parts of the healthcare system, and ensuring clinicians are aligned on a common goal.

Blue Cross Case Management program features:

• Complex case management for high-risk members with multiple comorbidities and high-cost claims, including complex medical, behavioral health, maternal health and oncology needs. Using predictive modeling we stratify member risk, with highest-risk members targeted for personal engagement and advocacy. For challenging and complex cases these services reduce inpatient utilization up to 25%.³
• Support for employees transitioning from inpatient settings, reducing readmission rates and emergency room visits. Through timely interventions and appropriate referrals, we reduce hospital readmissions by up to 13%.³
• Specialty programs for behavioral health conditions such as eating disorders, substance use and autism. Our programs reduce the potential for overuse or misuse of controlled substances by 54%, resulting in $0.07 PMPM savings per quarter.³
• Chronic condition management for asthma, chronic kidney disease, chronic obstructive pulmonary disease (COPD), diabetes, heart disease and heart failure. We close 17% of the gaps in diabetes care, reducing diabetes-related complications such as heart attack and stroke, resulting in $0.13 PMPM savings.

Case management model built on advanced analytics, clinical expertise

Blue Cross Case Management is designed to control total cost of care by producing better outcomes, ensuring appropriate use of medical care, reducing fragmentation and waste, and closing gaps in care. Our comprehensive approach is built on a foundation of advanced analytics and technology, paired with clinical expertise and holistic care models, to provide seamless support for members.

Early diagnosis and treatment can prevent medical complications and hospitalizations. Blue Cross has adopted a risk stratification model to identify high-risk members with complex medical and behavioral health needs, risk factors related to SDoH, and likelihood that they will need medical or behavioral healthcare. By stratifying members based on these risk factors, Case Managers can target interventions to prevent medical complications and hospitalizations that increase healthcare costs.

Blue Care Advisor is a front door for access to care

Blue Care Advisor^SM is an easy-to-use, all-in-one navigation solution that supports our Case Management program by encouraging members to close care gaps and guiding them to high-quality, cost-effective providers. Blue Care Advisor serves as a digital front door that helps employees understand and use their plan, get the care they need, when they need it, and stay on track with health goals. One location for benefits, programs and care navigation provides a simple, convenient experience.

Blue Care Advisor uses predictive analytics, machine learning/artificial intelligence models and real-time recommendations to guide members to high-quality providers and appropriate care. Blue Care Advisor users are two times more likely to seek and receive preventive care services than members who are not registered users.⁴ In addition, the clinical benefits and operational efficiencies of using predictive modeling and AI have saved $11.88 PMPM in avoided costs.⁵

Behavioral healthcare integration for whole-person health

Behavioral health conditions account for an estimated 57% of total healthcare costs,⁶ but integrating behavioral healthcare into medical care can lead to an 11% reduction in total cost of care.⁷ That’s why our case management approach integrates medical with behavioral healthcare to promote whole-person health.

To enable members to access behavioral healthcare wherever they live, Blue Cross nationally has expanded its mental health network by 55% over the past five years.⁸ We now offer virtual treatment options for substance use and eating disorders, so members can receive treatment at home without time away from work or school. And for children and young adults, we’re offering virtual intensive outpatient treatment with flexible scheduling, often within 24 hours of referral.

By recognizing behavioral health conditions early and integrating them with medical care, Blue Cross Case Managers can direct members to our expanded behavioral healthcare resources, including virtual care and alternative settings, enabling employees to recover faster and return to normal activities.

Addressing the growing cost of chronic disease

The number of people with chronic diseases is growing: 60% of adults in the U.S. have at least one chronic condition and 42% have two or more chronic diseases, such as asthma, chronic kidney disease, diabetes, heart disease, COPD or mood disorders.⁹ About 90% of the country’s annual $4.1 trillion healthcare expenditure is attributed to managing and treating chronic diseases and behavioral health conditions.¹⁰

Case Managers coordinate care for members with chronic conditions who often have comorbidities and see multiple specialists. Case Managers and providers discuss treatment plans and monitor progress toward goals, and support employees in adopting healthy habits when they leave the doctor’s office. Our data show that targeting clinical risk and actionable opportunity for engagement leads to higher overall cost reductions, including a 19% medication adherence closure rate¹¹ and 92% member satisfaction.³

Between doctor visits, Case Managers provide valuable support – an important effort, considering up to 80% of health is determined outside of the clinic or hospital.¹² Case Managers provide referrals to community programs and specialized support for maternity care and tobacco cessation. These programs help employees stay healthy and productive, halting disease progression to control total cost of care.

Effective case management is a winning strategy

Blue Cross is committed to programs that improve employee health outcomes and save employers money. Members who participate in our Case Management programs see up to a 19% trend reduction in medical costs.¹

Employers trust Blue Cross Case Managers to help employees navigate the healthcare system by teaming up with clinical experts, assessing risk, creating treatment plans and coordinating care for a smooth and effective healthcare experience. Helping employees access the care they need is our shared goal. By uniting clinical expertise with data and analytics, Blue Cross guides employees to appropriate care while controlling costs for employers.