Disease management program saves money
Technology boosts achievements
A comprehensive disease-management program that combines technology and case management has generated savings of between $450 and $1,700 a year for participating members in the Denver-based One Health Plan.
"The health of One Health Plan’s participating members has significantly improved, while the incidences of costly acute care events for members with specific chronic illnesses have decreased," says Wally Gomaa, MBA, MHA, president of One Health Plan, a subsidiary of Great West Life & Annuity Insurance Co.
For instance, medical services for asthmatics participating in the program has been $450 per year less than for nonparticipants. The diabetes program generated savings of $660 per year among participants. In the cardiac program, medical care cost $1,700 a year less for participants vs. nonparticipants. "It’s been a tremendously successful program. We’re not stopping here. We’re looking at other programs in the future," Gomaa says.
With more than 100,000 members enrolled, One Health’s CareResults program is the largest population-based disease management program of its kind," Gomaa says. "We are not the largest health plan, but we have the largest program in terms of participation," Gomaa says.
The program focuses on making the members more accountable for self-management of their conditions by educating them on lifestyle changes they need to make in order to stay healthy, Gomaa says. The program is available to the HMO, PPO, point of service, and indemnity population with no restriction on the ability to participate in the program.
"We have found that we can use low-cost interventions and achieve remarkable returns on investment as opposed to more traditional, very costly interventions," he says. The program was launched Feb. 1, 2000, and provides disease management services for people with four conditions: asthma, diabetes, pulmonary artery disease, and congestive heart failure.
The program uses technology to assign risks to patients with the four diseases, based on an interactive computer-based questionnaire. The majority of patients receive literature and test kits dependent on their condition, and are asked to take regular lab tests and do quarterly follow-ups. They receive training on "the language of care" so they can better communicate with their physicians about their conditions.
Higher-risk patients also receive interventions from the company’s nurse care managers who help coordinate their care. The information collected by the CareResults program is available on-line to the One Health Team nurse care management team. They use the information in their case management and support efforts.
"The bottom line is to balance resources with benefits. I would love to have every one of our 100,000 members interacting with the nurse, but we have to be able to generate positive returns," Gomaa says.
The program cuts down on nurse interventions by having them concentrate on the patients who need the most interventions, he adds.
Because of the diverse population the program serves, some nurses focus primarily on diabetes, others on cardiac problems or asthma. "These are our most highly trained nurses. They feel comfortable interacting with individuals with chronic conditions," Gomaa says.
One Health started off with a pilot program designed to achieve the accreditation goals of the National Committee on Quality Assurance, based in Washington, DC. In the pilot program, 85% of participants reported that they had learned new ways to manage their asthma and diabetes because of the program.
"The results were amazing. We found signification improvement in utilization of care, patient satisfaction, and incredible savings," Gomaa says. "We decided we would almost be negligent if we didn’t offer the program to our entire population."
One Health looked at 21 different vendors and chose Atlanta-based Landacorp for its disease management programs. Gomaa liked the Landacorp program because the company did not require One Health to delegate the utilization management function to them. "All interaction with members is done with our nurses, and there is no overlap with their nurses doing things one way and ours doing them a different way," Gomaa says.
Because the program is technology-based, One Health was able to reach its entire population of three million members and screen them for the four conditions. To identify potential participants in the program, One Health Plan and Landacorp developed a proprietary algorithm that looks at both pharmaceutical and medical claims. The data are based on ICD-9, CPT-4, and National Drug Council Codes.
About 12%-15% of the company’s total population was identified as potential participants. The program is run every month to identify other targeted candidates and people who did not respond. The health plan sends candidates a letter inviting them to participate in the CareResults program to help them manage their chronic condition. They are told that the program is free and that participation or nonparticipation will have no impact on their benefits.
If members agree to enroll, they receive a telephone calling card with two hours of free long distance. As they stay in the program, additional time is automatically added to the card. If people do not respond, One Health Plan’s call center staff calls them, offering to enroll them on the telephone.
Participants fill out a 20-minute health risk assessment either over the telephone through an integrated voice response system or over the Internet. The decision tree-based survey assessment measures how knowledgeable participants are about managing their condition, how receptive they will be to information on self-managing their condition, and self-reported severity of condition.
Patients who are determined to be at high or moderate risk receive follow-up. For instance, a participant with diabetes who understands what a hemoglobin A1c level is, knows his or her test results, and knows when he or she should be tested is given a low-risk factor and is not scheduled for follow-up during the year. (For details on the follow-up plan, see "Cusomized plan helps learn self-management," in this issue.)
The results of the survey are sent to the patients’ primary care physician or to the patient to be shared with his or her physician.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content