Wednesday, August 29, 2007

August 29, 2007 - My Friendly Neighborhood Case Manager

Today I speak by telephone with Kim, an R.N. who's employed by Care Allies (formerly Intracorp) – a company contracted by my medical insurer, the Presbyterian Church (U.S.A.) Board of Pensions (or perhaps by their contracted insurance company, Highmark Blue Cross/Blue Shield), to do case management for cancer patients. I've spoken with Kim a couple of times before, as she introduced herself to me and explained that she'll be available as a resource person, as I make treatment decisions. She works for Care Allies' Comprehensive Oncology Program.

Kim is helpful and professional, and seems very knowledgeable indeed about NHL and its treatment. She explains that, until recently, she worked for the CIGNA insurance company, managing care for stem-cell transplant patients (CIGNA evidently owns Care Allies, and contracts out their case-management services to other insurance companies – so, she still works indirectly for CIGNA). I'm favorably impressed with Kim. She has a warm and friendly way about her, and seems genuinely interested in me as a person – but, I'm under no illusions as to what her job is. It's the insurance company that writes her paycheck. They want her to become personally familiar with my treatment plan, so she can head off any costly treatments that may be less than medically necessary.

Kim and I are going to be traveling together through the gray area of medical insurance coverage – that gray area that has to do with the phrase "medically necessary." If Dr. Lerner, Dr. Portlock, or some other cancer specialist recommends a particular treatment, from now on the insurance company is going to subject that plan to a greater level of scrutiny. The insurance company has been doing that all along, to some extent – but now they have flagged my case as one requiring the dedicated, personal attention of one of their employees. With regard to my case, Kim is the insurance company's human face (or, I should say, their human voice – I've never met her in person). She and I are allies – up to a point. I sense, from her demeanor, that she'd genuinely like to see me get better – but, at the end of the day, her job is going to be to recommend more affordable alternatives, if such are available.


Here's what the Care Allies website says about the role of the case manager ("you," in this case, refers to the insurance company contracting for their services, rather than to the patient):

"How it works for you.

Our case managers reach out to the patient to provide assistance and help providers deliver positive results. Through personal interaction, our case managers can address the patient's needs, care environment and available alternatives to help optimize outcomes. With years of experience and knowledge, we can apply an integrated approach across the entire continuum of care.

Empowering your employees through health advocacy.

When employees know they have an advocate to help them deal with a difficult health condition and assist with navigating the complexities of the health care system, we believe they're likely to be more satisfied with their benefits program – and get well faster. CareAllies offers services administered by Intracorp that have been awarded accreditation from URAC, an independent organization whose mission is to help ensure consistent quality care for payors and consumers.

We Make a Difference.

As our customers fight the pressures of health care inflation, CareAllies' Case management services can continue to add value through experience, expertise and efficiency. We are uniquely equipped to link case management with its other health and productivity management services. The result is appropriate actions that can help ensure early intervention, and positive health outcomes for employees, and increased savings for employers."


"Positive health outcomes" – we all want to see more of those. But, positive for whom? For me? For the Presbyterian Church (U.S.A.)? For the insurance company? Suddenly, as I drive further down the treatment highway, more and more people seem to be showing up in the car.

I'm sure there are ways Kim will be genuinely helpful, in guiding me through the bureaucratic maze of insurance review and approvals. She's already starting to do that, offering to check for me on whether Hackensack University Medical Center – where I'm going on September 10th, for a consultation with Dr. Michele Donato about testing for a possible future stem-cell transplant – is inside or outside the insurance company's network. If I'm going to get a "no" from the insurance company regarding some future treatment, I suppose it would be more congenial to hear it personally from a specialist who knows my case, than by pulling some computer-printed letter out of a window envelope. Yet, a "no" is a no – even if it's the more congenial variety. I'm hoping I won't be hearing that word, from Kim or from anyone else. But, time will tell.

An image comes to mind: of Humphrey Bogart, Walter Huston and Tim Holt in the classic Western, Treasure of the Sierra Madre. Those three grizzled prospectors find themselves thrown together as traveling companions, each of them owning a partial share of a gold mine. On the surface, they're friends and allies – but always there's a certain tension underneath, because of the gold. Will they protect one another's interests? Or, will one of them betray the others, to gain a larger share of the gold?


In the movie, their partnership does not end well. I hope Kim, my doctors and I will do much better.

3 comments:

Vance Esler said...

As they say, follow the money trail.

Kim's job is to save the insurance company money, yet keep you happy. But between those two goals, the first is foremost.

You can bank on that.

;)

Anonymous said...

During my hip surgery adventure - when Intracorp was still the provider, my personal case manager was actually quite helpful in getting payments worked out. In fact, I continued to contact her long after our "relationship" had ended and I was dealing with other insurance issues - she cleared the way for me a time or two. I hope Kim is similarly inclined. Once something IS approved, they can help YOU sorting out paperwork and disputes with providers. Robin

Carlos ("Carl") said...

9/20/07

Robin,

Actually, I've just learned from Kim that they're going to be transferring my case to a different case manager, who works specifically with stem-cell transplants (Kim works with general oncology cases now, although she does have extensive prior experience with stem-cell transplants). Actually, I'd rather not make the switch right now - especially because the stem-cell thing is still a hypothetical - but, as she explained, it's pretty much mandatory, once charges start to come through from a stem-cell center (as they soon will, for the testing of my brothers as possible donors).