Enhancing the case manager's role through early identification of at-risk members

This article describes a methodology to improve early identification and stratification of at-risk patients with comorbidities that could result in catastrophic illness. Data from the HMO line of business identified diabetic members. Total frequency and total cost for 19 comorbid diseases were calculated on data from the diabetic members who were classified as having high severity and comorbidity rankings. Members were further segmented into quadrants based on frequency and cost for referral to case management and/or educational programs. A total of 1312 HMO diabetic members were classified as high severity. Quadrant 4 diabetic members consumed greater than $10,000 in health care expenses and had 6 or more collapsed DECs. Similar types of comorbid diseases were found in both quadrants 2 and 4. Quadrant 2 diabetic members were identified as "in danger" members with the potential to incur total costs greater than $10,000.