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.

FHP: Can you describe some examples of the types of outreach case managers provide?

Kosman: There are cases that we look at in a few different ways. One way is that you might be making an outreach on a particular type of trigger where you're anticipating that you might be doing some situational education. For example, a member might utilize an emergency room for something that could have been equally handled in an urgent care facility or physician office.

At the outset, you might be making that outreach to explain benefit differentials for utilizing different types of services to help understand why they went to the ER. In some cases, those calls might be a one-time outreach because circumstances were such that in the moment it made sense but now they understand their benefits, they have a primary care provider and they're going to make that connection going forward.

But you could have that same call and find out the member has been utilizing the ER more regularly because they haven't established that primary care connection or they really don't understand the implications of their disease process or the incentives aren't aligned for them to get to the doctor's office instead of the ER. So that call might be equally about educating the member about the benefits, but also may continue to be about helping the member link to a primary care provider and determining whether there are other options in their geographic area so they're not dependent on the ER for routine care.

Case managers might also look to see whether there's an appropriate program to engage the member in to help manage their symptoms so they don't need the ER.

So we do have some cases that may close relatively quickly after a few calls and some where we stay engaged for many months.

FHP: What kind of education and background do your case managers have?

Kosman: We actually have a mix of case managers. The vase majority of them are registered nurses, and many of them have a bachelor's degree. We look for individuals who have at least three to five years [experience working] in a clinical setting because we want individuals who are coming with an understanding of disease process and hands-on care.

But we also have social workers, behavioral health specialists and psychologists. We do find having that mix is really quite valuable in terms of leveraging the clinical expertise and acumen across those disciplines, as well as across clinical settings because we have quite a variety of clinical expertise, from pediatrics, oncology, rehab and pretty much every specialty out there.

FHP: Do you think a case management program like Aetna's will help set the company apart in the evolving consumer-oriented market?

Kosman: When we think about individuals who are going to be on the market in the [health insurance] exchange, they really are a mix of individuals. Case management is going to become even more important than it already is in understanding where a member is to help align them with the right program. Individual members don't really know what they have until they need it, so especially on the exchanges in the absence of benefit managers, case managers are going to play an enhanced role to the member navigating the healthcare system potentially for the first time.

Case managers are uniquely positioned to make that strong connection between helping individuals navigate [insurance choices], as well as assisting them in understanding whatever circumstance or condition brought them to need those services in the first place. They also can help make individuals better consumers to use the tools that are available.Case managers really can be an essential link and a real advocate for members in that space.

Editor's Note: This interview has been condensed and edited for clarity.

Read more on