Cooperative Care

To take care management to the next level, BlueCross BlueShield of Tennessee brings disease management in-house.

Chattanooga-based BlueCross BlueShield of Tennessee (BCBST; more than $8 billion in annual revenue) historically outsourced its disease management programs for members suffering from chronic diseases. "When someone is really sick, personalized care decisions have to be made, and that is where case management comes in," explains Chris Levan, CIO of BCBST.

In 2003, however, as the industry started becoming more consumer-focused, BCBST decided to pursue competitive advantage by providing more-personalized customer service in the form of specialized care and disease management. "We decided that we needed a second generation of care management to improve the overall delivery of healthcare," says Levan. To add disease management capabilities in-house, the carrier implemented Newport Beach, Calif.-based TriZetto's CareAdvance Enterprise care management system in 2005.

Levan says he sought a solution that would leverage the carrier's existing core processing systems, which run on IBM's (Armonk, N.Y.) AIX operating system in an HP (Palo Alto, Calif.) environment, and pull data from disparate sources, adding that BCBST evaluated several vendors' systems. "The new system would be able to coexist with our current infrastructure and utilize the right data," says Levan. "We didn't see anything else that fit our requirements."

Using rules-based automation, CareAdvance Enterprise, built on a Microsoft (Redmond, Wash.) SQL Server database and Microsoft Windows Server 2003, coordinates care management workflows and enables secure collection and aggregation of member data in a single repository, according to TriZetto. The solution identifies high-risk cases and members with chronic conditions through criteria such as diagnosis codes on claims, and facilitates information sharing among care management nurses, doctors and other stakeholders to ensure patients get the best care. "It externalizes the workflow, and this makes it easier and less time-consuming for nurses to collaboratively improve the patient's health," asserts Levan. CareAdvance also has a member portal, which allows consumers to actively participate in their care and develop a personal health record.

In just six weeks, TriZetto helped BCBST create a disease management pilot in April 2005 for Medicaid members suffering from diabetes. Based on the success of the pilot, BCBST extended program eligibility to all of its more than 700,000 Medicaid members for conditions including cardiac heart failure, asthma and high-risk maternity. Currently, the insurer is rolling out the service to its 1.8 million commercial members and expects to add additional lines of business to the program over the next several years.

The cost of the initiative was $300,000, Levan relates. But the carrier anticipates a significant return on the investment, he notes. "We will be able to administer these programs for a fraction of the cost of outsourcing," says Levan. --Maria Woehr