Managed Medicaid

CareSource Starts Marketing Nurse Triage Tool to Other Medicaid Plans

Reprinted from the Oct. 27, 2005, issue of MEDICARE ADVANTAGE NEWS, biweekly news and analysis on the Medicare (and Medicaid) managed care programs.

CareSource, Ohio's largest Medicaid managed care plan, is starting to market its expertise with a 24-hour nurse triage telephone service to other Medicaid managed care organizations (MCOs), and is considering marketing the tool to states later this year as an adjunct to primary care case management (PCCM) programs, a top plan official says.

Though declining to put a dollar figure on CareSource's cost of starting and operating the service, Janet Grant, senior vice president for business development and regulatory affairs at Dayton, Ohio-based CareSource Management Group, describes it as "a huge investment to staff a line with registered nurses 24 hours a day, seven days a week." Yet she says the MCO's return on investment on its two-year-old triage tool has been large and immediate, making the company eager to parlay its expertise beyond its own membership.

"We determined that more than 60% of the time we're able to divert [callers] to a more appropriate level of care," Grant says. Assuming 6,000 diversions at an average cost of $220 per emergency room visit, "that brings us over $1.3 million in savings" annually, she says. On the flip side, she says that 6% to 8% of the time a member calling the service who's not planning to seek medical help has been urged to go to the emergency room — cases in which she says "members credit us with saving their lives."

"Given the fact that the models being adopted by states to manage care are evolving and becoming more diverse, there seems real merit in being able to offer services on an unbundled, a la carte basis," says Robert E. Hurley, Ph.D., associate professor in the Dept. of Health Administration at Virginia Commonwealth University. "This is an approach that has been used by some of the major commercial managed care plans for some time with good success as they try to focus on what customers want to buy rather than just on what they would like to sell to them."

Grant describes CareSource's triage service as an important screening tool, offering a chance of "taking that one opportunity when [members] contact us to move them into appropriate care management." And, she says, while this is CareSource's first attempt to market its expertise with a salable product, the MCO is "always looking at where we have core competency that would be attractive to other plans in other markets."

CareSource Management Group's nonprofit managed care plans serve 362,000-plus Medicaid members in Ohio and nearly 70,000-plus Hoosier Healthwise members in Indiana, according to company officials. It administers Community Choice Michigan, a nonprofit managed care plan serving about 50,000 Medicaid enrollees in Michigan.

CareSource sees the nurse triage venture as "an investment, more cost-effective than outsourcing [nurse triage] to an outside vendor," especially as the company continues to grow, Grant says. The firm brought the triage service to Indiana, where the MCO recently entered Indiana's Medicaid managed care program that requires only an after-hours answering service. Its triage tool also is used as part of the package of services provided to Community Choice Michigan.

Two Competitors Express Interest in Product

"We felt this was kind of a missing piece out in the market..We're trying to diversify, and every Medicaid plan we told about our services indicated interest in the nurse triage line," Grant says. In marketing its nurse triage service in Ohio and Indiana, CareSource has been approached by two competitors expressing an interest in the product, she says. "It would be challenging to put up a firewall," she notes, explaining that ultimately the MCO expects to focus on markets outside its own service areas.

Initial marketing of CareSource's nurse triage tool began in the summer, specifically targeting Medicaid plans of 20,000 or more members. There are no customers yet. Grant notes that large Medicaid players often have access to such a service, while the cost might be too high for smaller plans. "We have to see enough volume to make the contract worthwhile to us," she says.

Historically, CareSource has been required under Ohio's Medicaid program to provide 24-hour-a-day/seven-day-a-week nurse triage in an effort to reduce overutilization of emergency services, Grant explains. Before acquiring a large membership, CareSource used outside vendors for this service, she says, but the MCO didn't see a decrease in unnecessary emergency utilization, and some members were directed inappropriately to out-of-network providers. Thus, she says, CareSource decided it could do a better job by using a triage line in conjunction with its own case management program.

In mid-2003, CareSource decided to bring the triage service in-house in order to serve its membership of around 175,000 at the time, Grant says. She says the MCO recruited leadership from other nurse triage programs to set up an infrastructure, hiring staff with expertise in emergency and pediatric care settings, and identifying an outside vendor's software package of care guidelines to use. "The service was launched in early fall '03, and we started to see immediate return on investment," she says.

Grant says CareSource uses 20 to 25 nurses for 24/7 coverage, and staffs its call center based on call volume. Most calls occur in the late morning or early evening. "I would say the 'new mother' calls are the majority, but it depends on the season," she adds. "Flu season means flu calls." All calls are taken at a single call center, but the nurses know where the member is calling from.

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