Patient selection plays an important part
When first introduced several years ago, many proponents hailed disease management (DM) as the be-all and end-all of employee health programming. In the harsh light of reality, some programs have proven to be more sizzle than steak while others have generated significant health improvement as well as bottom-line savings.
What sets one DM program apart from another — or, more importantly, what are the keys to disease management success? According to one observer, it begins with the very foundation of the program.
"There are a variety of things that contribute to the success of a disease management program, but for us I believe it starts with a skilled clinical team, population identification and predictive modeling," says Betsy Rose, manager of marketing and communications for Health Management Corp. (HMC), a Richmond, VA-based company that offers integrated health and disease management services, including health risk assessments, a 24-hour nurse line, employee assistance programs (EAPs), and Baby Benefits, a high-risk maternity management program.
HMC’s disease management programs have earned the C. Everett Koop National Health Award and the Health Industries Research Companies 2001 Top Ten Disease Management Company in America award. HMC programs have about 200,000 participants nationwide.
In-house expertise
HMC employs an interdisciplinary clinical team in its headquarters facility. "Lots of disease management programs will tell you their nurses are great," says Rose, "But we integrate registered nurses, a health educator, on-site pharmacists and a dietitian — which is a rarity in the field."
She explains that part of HMC’s intervention strategy is to identify the needs of the patient and the physician and to help coordinate care. "They may have questions about meds, and we can get the physician and the pharmacist on the phone either with the nurse or in a three-way conference with the patient," Rose says.
But the system really begins by identifying those employees with specific high-risk diagnoses. "We identify them in rank order in terms of those most likely to have the greatest need in the future," says Rose. "We look at the past two years of claims in making our predictions, and identify those who we expect to work with in an intense care management intervention. That’s a big key to our success — knowing who’s out there and the severity of their condition; choosing the ones who need the highest level of care."
Through AccuStrat, its proprietary predictive model, the identified individuals are ranked in order. Then, using its Healthy Return System, the care management intervention is driven. Participants also have 24-hour nurse access and access to their medical records.
At present, HMC provides DM programs in asthma, diabetes, coronary artery disease, and congestive heart failure. In December 2002, it will launch its COPD (chronic obstructive pulmonary disease) program.
Care management interventions in these areas include:
- Coordination of health care services and ancillary referrals;
- Disease-specific and comorbid management;
- Pharmacy and nutritional counseling;
- Lifestyle management and behavioral change counseling;
- Disease-specific educational materials;
- Automatic re-stratification from claims and patient-reported data.
"We look at the participant’s total health — all comorbidities, not just what they are diagnosed with," Rose explains. "We mail and fax the physicians to help them understand what the program is and how we reinforce their care with the patients between office visits." The program also has a web component, "But from what I’ve seen in the industry, you can only expect about 5% utilization," she explains. "Right now, it — as well as e-mail — is used for enrollment and educational resources. We’ve seen other companies go full force with web service, but we waited to see what it looked like," Rose explains. "There are also issues of confidentiality, and we’re not sure what the rules will be."
Numbers tell the story
Over the past several years, HMC has recorded impressive results for its DM programs in areas such as reduced emergency room visits, lower claims and patient admissions.
More recently, it conducted a rigorous study of 76,194 members and 2,359 diagnosed participants. Each group was tracked for the year prior to DM implementation (1999) and the year following implementation (2000). The study included asthma, diabetes, and coronary artery disease.
The study analyzed the financial return of the DM program by comparing expected claims costs, which were calculated from a control group using a statistical model, to actual claims costs for the study participants. This control group included individuals whose PPO benefits managers did not purchase HMC’s DM programs.
The results? The improved outcomes associated with the DM program yielded a net savings of $1.09 per member per month.
[For more information, contact: Betsy Rose, manager of marketing and communications, Health Management Corp., P.O. Box 26016, Richmond, VA 23260. Telephone: (800) 523-9279. Fax: (804) 354-5047. Web site: www.choosehmc.com.]
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