Helping members manage disease lowers cost trends
Savings translate to overall membership
A comprehensive program that helps members manage the five most common chronic diseases has lowered medical cost trends by 1.5% to 2% for all members in Independence Blue Cross's Medicare, HMO, and PPO plans, according to a recent cost-savings analysis.
The study showed that the medical costs incurred by the entire membership, not just by the members with chronic conditions, were 1.5% to 2% lower than it would have been if the health plan had not instituted its Connections Health Management Program, says Esther J. Nash, MD, senior medical director, population health and wellness, for the Philadelphia-based health plan.
"Comprehensive evaluation shows that with our Connections program, we were able to reduce cost trends across all of our lines of business. When the savings were calculated for those members with chronic conditions, they were significantly higher," she says.
About 235,000 members have one of five most common major chronic conditions — asthma, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease — and 98% of them participate in the Connections program. The Connections program offers educational materials, health reminders, and access to a health coach 24 hours a day, seven days a week.
The insurer's health management program began in 2003 with five conditions and has expanded to 21 chronic and complex conditions, including Parkinson's, lupus, and multiple sclerosis.
Connections is part of Independence Blue Cross' comprehensive health and disease management program, called Healthy Lifestyles. Healthy Lifestyles includes a wide range of support services, such as incentive programs for making health choices such as going to the gym, quitting smoking, or losing weight.
"We have made a commitment to our region to make sure our members can stay healthy. We offer our members a portfolio of health promotions programs and preventative health. We offer a workplace wellness program as well as tools on our web site that members can use to manage their health," Nash says.
The goals of the Independence Blue Cross Connections program are to prevent complications and relapses of chronic conditions and to make sure that chronically ill members receive all recommended tests and treatments, Nash adds.
Member satisfaction with the program has been high. Among members with chronic diseases responding to a membership satisfaction survey, 94% were satisfied with the help and support they received and 90% indicated that speaking with a health coach improved the quality of care they received from their doctor. In addition, 74% of respondents reported that speaking with a health coach improved their ability to talk to their physicians.
Data analysis
Members eligible for the program are identified through analysis of medical claims, pharmacy claims, laboratory claims, lab values, utilization data, the results of personal health profiles, and referrals from primary care physicians.
The health plan has four nurses in the field who visit primary care physicians to support the Connections program. The primary care physician can make a referral by telephone or fax for members who may be eligible for the program.
At the heart of the program is Independence Blue Cross' data analysis, which mines claims and utilization data to ensure that the health plan is reaching all members and getting them into the program in a timely manner.
"We know that the program cannot be static. There are built-in lags with using administrative data because it takes time for claims to come in. Recognizing the built-in delays, we are analyzing continuously to identify members as quickly as possible," Nash says.
The daily analysis finds new eligible members and restratifies members with chronic conditions. On a daily basis, the program identifies any member with chronic conditions who has been discharged from the hospital and notifies the member's health coach, who makes an outreach call.
The health plan's data analysis also looks for gaps in clinical care, such as treatments or tests recommended by clinical guidelines for the member's condition. When the data mining identifies members who haven't gotten any of the recommended tests or procedures, such as a hemoglobin A1C test or a lipid screening for diabetics, it triggers communication, either by mail or a health coach telephone call.
"It's a dynamic and continuous model. We are committed to using every source of data available to identify and target members," Nash says.
Once members are identified, the health plan applies algorithms to stratify them for targeted outreach.
"We use a predictive model approach. We are not only targeting the members who received care in the past. We use our data to attempt to predict in the future who is likely to have the greatest medical needs and costs," Nash says.
Health coaches
All members in the disease management program receive educational materials, health reminders, and access to a health coach 24 hours a day, seven days a week. They are asked to fill out and return a health risk assessment, which the health plan uses, along with current and historical data from the member's case history, to stratify members into risk levels.
Members who are stratified as being at high risk receive outreach calls from the health coaches.
The health coaches are specially trained health care professionals who may be nurses, dietitians, or respiratory therapists. They help members understand their conditions and treatment options. The health coaches are available around the clock to help members with general health information as well as to coach them on significant clinical treatment options.
The health coach establishes a relationship with the member, discusses any other health issues that can affect the condition as well as family or other personal issues that can have an effect on the member's health. They talk with the members about upcoming provider visits and emphasize the importance of recommended tests or treatments.
"The health coach discusses the three or most important things the members should talk about with the doctors and follows up after the visit for reinforcement and support," Nash says.
The health plan designed a fully integrated program in which members' care is seamlessly coordinated by both internal and outsourced resources, depending on each individual member's needs.
The Connections disease management programs are provided by Independence Blue Cross in partnership with three disease management vendors.
The health plan's internal case managers coordinate the care of members who are hospitalized or who need more intensive management.
The health coaches and internal case managers work together to ensure that the member gets the care he or she needs without duplication. The case managers help members navigate through the health care system, get the treatment they need, and understand the physician's treatment plan.
Communication is ongoing
Communication between the case managers and health coaches is ongoing, and each part of the team has access to the other's data platforms.
"We make sure members get all the services that benefit them without being redundant. When a case manager logs onto a member's name, a window comes up telling them that the member is in the Connections program. They can view a history of the outreach and interactions. It's part of our commitment to integration and a seamless program of care," she says.
"To be successful, a program has to have skilled case managers and health coaches talking to the right people at the right time. We can't afford to have them calling people who don't need help as much as somebody else. The program is integrated with built-in work flow and communication databases that allow every component to interface instantly," she says.
The health plan developed an on-line referral mechanism through which the health coach can refer patients to the internal case manager and vice versa. Some of the health coaches from an outside vendor are on site at Independence Blue Cross headquarters, literally sitting next to the health plan's internal case managers.
"The vast majority of health coaches that serve our members are located in operational centers in other places. We have deliberately co-located a number of them in our headquarters to work closely with our internal case managers. They not only refer members electronically, they can talk across their cubicles and ask advice of each other," Nash says.
The health plan also offers members shared decision-making assistance to help members decide on the best course of treatment for them.
If a member is going to a specialist for evaluation on a condition, such as chronic back pain, the member receives an outreach mailing or an automated telephone call asking if he or she would like support on treatment options.
If the member wants help, he or she gets a videotape of treatment options and is educated to have a productive discussion with the provider and to make a decision about the treatment.
A comprehensive program that helps members manage the five most common chronic diseases has lowered medical cost trends by 1.5% to 2% for all members in Independence Blue Cross's Medicare, HMO, and PPO plans, according to a recent cost-savings analysis.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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