Contracting for DM pays off for small insurer
Plan saves on cancer treatment, heart attacks
When the management at CHA Health realized the need for disease management services for their population, they decided to contract with outside providers rather than establish the programs themselves.
CHA Health chose to purchase disease management programs rather than creating them in-house because it is a small company with limited resources, says Timothy D. Costich, MD, chief health services officer.
"Disease management is very time-consuming and very resource-consuming if you do it yourself. For active intervention in an identified risk population, you have to have the resources to develop the protocols and manage the program," Costich says.
Large, national companies have the experience and the expertise and are able to spread their resources over a large population base, making their services more affordable, he adds.
CHA Health is a Lexington, KY-based managed care organization created by local medical providers with more than 140,000 members in central and eastern Kentucky. About 70,000 members are fully insured by CHA Health and are eligible for its disease management programs. The others are employees of self-insured companies.
CHA Health has a lot of members in a wide geographic area. Many live in rural areas. Their needs are different from the needs of populations in other areas, Costich says.
"Telephone disease management works in other areas or with self-insured employers with multiple sites. But we need a hands-on approach with our population. We knew that just calling people on the telephone or sending them a booklet in the mail wasn’t going to work for our population," Costich says.
The insurer started with two of its costliest diagnoses: heart disease and cancer.
Healthy Horizons, a program for oncology patients undergoing active treatment, was rolled out in September 1999 and is managed by McLean, VA-based Quality Oncology, which specializes in managing care for cancer patients.
Healthy Heart, which focuses on early detection and treatment of coronary artery disease, was launched in March 2000. Q-Med, a Laurence Harbor, NJ-based disease management company offering technology-based management for cardiovascular disease, administers the heart program.
"For reasons of mostly lifestyle choices — smoking, obesity, Type II diabetes — we see a lot of heart disease. It’s the condition upon which we spend the most money," Costich says.
"When we chose our heart attack program, we were looking for a program that was preventative. We were not particularly interested in managing people who were already sick," Costich says.
In its first year, Healthy Heart achieved a dramatic reduction in heart attack incidence. Q-Med reported that the incidence of heart attack had been reduced by 35.8% for the total CHA Health membership.
"In addition to utilization numbers, we’ve had a big increase in our HEDIS [Health Plan Employer Data and Information Set] numbers in terms of appropriate medication and appropriate monitoring of outcomes," Costich says.
He’s waiting to see if the second year’s results will be as dramatic or if the gains were based on a change in population.
"If you are doing prevention and identification properly, ultimately you will have a reduction in the number of events," he adds.
The staff at CHA Health didn’t just turn management of its heart and cancer patients over to the vendor — they stay involved on a regular basis, reports Kim Lee, director of medical management.
"It’s very important to realize that none of these programs work in isolation from each other. A joint effort at communication back and forth is extremely important," she adds.
CHA Health has a liaison case manager with each disease management program. The case managers do discharge planning, coordinate benefit coverage with local resources, set up home health or other programs that the patients need, and collaborate with the disease management company case managers on challenging cases.
The staff have ongoing monthly and bi-monthly conference calls with the vendors, as well as more frequent contact to make the most of the disease management efforts, she adds.
The Healthy Horizons cancer management program focuses on applying up-to-date protocols that use evidence-based medicine, Costich says.
"If you’re doing it right, you typically save money on cancer treatment," he says.
Participants are identified through claims data, referrals from case management, and from local oncologists.
Quality Oncology assigns a primary case manager to the CHA Health cancer population. The case manager looks at the chemotherapy protocols that are proposed, the lab results, the biopsy results, and does day-to-day utilization management of the cancer population.
The cancer program is available for members undergoing active treatment. The member is assigned a case manager who works with the patients and family by telephone, answering questions and helping facilitate the treatment plan.
"The case managers look at the appropriateness of the treatment plan the oncologist puts together and looks for duplication of services," Lee says.
For instance, the family physician may order a battery of tests and refer the patient to specialists who do the same tests.
Participants in the Healthy Heart Program are identified by their physician or through patient self-reporting. CHA Health puts information in the member newsletter and sends letters to primary care physicians to identify people who are at risk for coronary artery disease.
"We look at claims data many times a year," Lee adds.
When a patient is identified, Q-Med staff go to the patient’s primary care physician office, take a patient history, examine the patients, and stratify the patients into risk categories. The company uses a proprietary technology system to assess, stratify, and manage the patients.
The Q-Med case managers work with the physicians to make sure they follow standard protocols for patient care and work with the patients on lifestyle changes, Costich says. "We haven’t had any complaints from our physicians. It’s hard for them to say they aren’t interested in learning the best way to treat heart disease."
The program saved money in the first year as costs for heart attack incidence declined. "It’s somewhat of a moving target. Costs change every year, and our population also changes," he says.
Four tips for planning a successful DM program
1. Decide what you are trying to accomplish and make sure your vendors will meet your needs.
2. Find out what type of intervention will generate the best response from your members. For instance, CHA Health in Lexington, KY, chose a program that worked with patients in person, rather than via the Internet or telephone.
3. Choose your diagnoses carefully. For example, CHA Health started with the disease that cost it the most money. "Our strategy has been to do things that save the most money and inaugurate programs that will pay for themselves," says Timothy D. Costich, MD, chief health services officer at CHA Health.
4. Keep your disease management programs to a level that you can handle. "Some companies do all their disease management programs at the same time. One disease management roll-out a year is as much as we can do," Costich says.
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