Home-grown disease management programs reap rewards for insurer
Plan sees advantages to developing its own programs
When ConnectiCare looked into starting disease management programs six years ago, there were few similar products on the market. So, the small regional HMO based in Farmington, CT, decided to create its own disease management programs.
ConnectiCare is an independent practices association (IPA) model HMO with 260,000 members in Connecticut and western Massachusetts. The plan established its first disease management program in 1996.
One of the first programs, BREATHE, an asthma program, achieved a 119% return on investment.
"At the time, there weren’t a lot of vendors out there because it was a new concept. We thought it was in our best interest to develop our own program. We wanted to have them in-house, and we saw it as an opportunity to learn something about the industry rather than just outsourcing it," says Jay Salvio, BSN, MBA, director of ConnectiCare’s health management department.
The company wanted a program with a personal touch to make it a "true ConnectiCare program," Salvio adds. ConnectiCare’s philosophy was to be member-oriented and keep as many operations in-house as possible.
"We wanted our staff from Connecticut dealing with our members. We wanted a program that had a real personal touch and fit in with the case management aspect," says Steve Delaronde, MPH, MSW, an epidemiologist/research analyst with ConnectiCare’s health management department.
In fact, the members appreciated having someone from the organization they were familiar with being part of the disease management program and welcomed the chance to form a relationship with their insurance company.
ConnectiCare’s member satisfaction ratings soared after the disease management programs were implemented.
"One of the most important aspects of what we are doing is creating a personal connection with the members. This is also one of the areas where you get the greatest return. It helps distinguish your organization within the marketplace and helps you carve a niche and build your reputation," Delaronde adds.
The plan’s oldest disease management program is a high-risk pregnancy program, which started as a quality improvement activity and evolved into a health management program.
"It was born out of concern about the number of pre-term deliveries we were experiencing five or six years ago. We felt that with proper education and management, we could reduce the number and improve the quality of life for members and their children," Salvio says.
The company has created additional disease management programs in asthma, diabetes, and congestive heart failure. The programs typically are staffed by two nurses and a support person.
The HeartCare program, which previously focused on members with congestive heart failure, will begin serving members with coronary artery disease in 2002. Two nurses and a support person will staff the HeartCare program, with a nurse dedicated to each.
ConnectiCare’s disease management plans were developed by a committee that included a physician advisor who was a specialist in the chosen condition. Other committee members included the director of the health management program, the nurse or nurses who would be operating the program, and the plan’s medical directors.
A lot of the work was done in the background and brought to the committee for approval, Salvio says.
For each diagnosis, the plan’s disease management committee creates guidelines to guide the management and education of members and the physician community.
The staff at ConnectiCare recommend using established guidelines rather than developing your own.
For the asthma disease management program, ConnectiCare used the National Heart, Lung, and Blood Institute guidelines for managing asthma.
It takes ConnectiCare about four to six months to develop a disease management program and go live with it. "We started our coronary artery disease program in January and plan on having it go live in June," Salvio says.
Patients are identified by utilization — either claims for the physician office, emergency room, hospital, or pharmacy.
The plan uses pharmacy claims and lab data to identify patients who are not having problems at present but may in the future.
For instance, diabetes patients with high cholesterol or A1C hemoglobin levels are identified. The system flags asthma patients who are refilling their short-term "rescue" medications frequently and seldom refill their anti-inflammatory medication for long-term control.
They are stratified according to how they are identified. For instance, those who have been hospitalized or treated in the emergency department get the highest level of management from the case manager.
"As part of the evolution of health management, we started by identifying members once they had experienced some event, and helped them improve their health status. Our goal is to move further upstream and try to predict who may end up in the hospital and prevent hospitalization by getting them into the program before their condition gets severe," Salvio says.
Once members are identified, the case managers personally contact those in the high-risk group. The rest are sent materials to educate them about their condition and help them manage it.
For instance, in the asthma case management program, nearly 400 of the 23,000 members with asthma are under active case management.
When they contact high-risk patients, the case managers assess their level of knowledge about their condition, determine what they need in terms of management help and education, and then put together a treatment plan.
The ConnectiCare disease management committees have developed standard protocols for typical situations that the case managers use unless the patient has unique comorbidities.
The patients receive follow-up telephone calls as needed. While the primary focus of the disease management program is the members, Connecti-Care makes sure that patients’ treating physicians are in the loop.
The physicians are sent up-to-date guidelines annually, and quarterly patient utilization and drug profile reports.
"We don’t operate apart from the patient’s regular medical care," Delaronde adds.
Get on the disease management bandwagon
Whether you’re an insurer, provider, or an independent case management firm, you need to be doing disease management in order to keep up with your peers. More than 90 million people in the United States suffer from at least one chronic condition. Their care makes up 60% of the nation’s total health care expenditures, according to the National Center for Chronic Disease Prevention and Health Promotion. Managing chronic diseases is the most effective way to address escalating health care costs. For instance, the national chronic disease center estimates that every dollar spent on diabetes management saves $2 to $3 on hospitalization costs. In this issue, we’ll show you how two organizations, an MSO and an HMO, set up and run their disease management programs. We include tips on setting up your own program. You’ll learn about the Joint Com-mission on Accreditation of Healthcare Organization’s disease-specific certification program and see how a hospital developed a clinical reminder for case managers to document patient education.
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