Focus on preventive care pays off for health plan
Program rewards staff, members for HEDIS measures
By using state-of-the-art technology to ensure that members receive preventive care measures and rewarding staff, physicians, and members when the preventive services are rendered, Health Plan of Michigan has increased its membership dramatically and is ranked No. 10 among the Nation's Best Health Plans by U.S. News & World Report and NCQA.
The ranking is based on the health plan's achievements in preventive care, appropriate treatment, and customer satisfaction, and is largely based on the health plan's scores on the Healthcare Effectiveness Data and Information Set (HEDIS) performance measuring tool administered by NCQA.
"We believe that ensuring that members get more care, rather than less care, saves health care dollars in the long run. Our mission is to reach out to every member to educate them about necessary preventive services, which keep them healthy and out of the hospital," says Thomas L. Lauzon, executive vice president and chief information officer of the Detroit-based health plan.
The plan was founded in 1997 with four employees and 800 members in one Michigan county. This year, it has 125 employees and 146,000 members in 42 counties.
"What makes our health plan unique is our use of technology to make all our processes incredibly efficient and effective. All of the technology centers around our proprietary Managed Care System [MCS] technology system. No one needs to remember to send post cards or make outreach calls. Everything happens automatically through the system," says David B. Cotton, MD, president and CEO.
The health plan's technology system is designed around care management and quality of care, not claims processing, Lauzon says. It provides real-time information to health plan employees and providers, enabling them to see at a glance whether the member has had all the recommended tests and preventive services. Any time a health plan staff member or provider accesses the member's records for any reason, the computer system indicates with a red "H" if the member has not received one or more preventive services covered in the HEDIS measures.
"Anybody who touches the member is aware of whether the member needs preventive services. Preventive care saves lives and helps our bottom line," Lauzon says.
For instance, if a member calls the member services department to change primary care physicians and the staff member notices that a child is missing an immunization, the system generates a script that the staff use to explain why the immunization is necessary. If the member has a problem getting to see the doctor, the health plan staff offer to set up free transportation or schedules the appointment for the member.
Then, 90 days later, if a claim for the missing immunization hasn't come in, the member hasn't received the immunization, the information about the missing services goes back into the record for the member to be contacted again.
As claims come in and HEDIS measures are satisfied, the system is updated in real-time.
"Everything in our system is integrated. Claims data, membership information, HEDIS data, and provider information are available to everyone, including providers. When they pull up a member file, they can see automatically what preventive services the member needs to receive," Lauzon says.
All employees have the ability to earn sizeable bonuses if the health plan hits its goals for all HEDIS measures.
If the company exceeds the NCQA 50th percentile, each employee gets a bonus for that measure. If the figure rises to 75%, employees get a higher bonus. If the health plan ranks in the NCQA 90th percentile on a measure, the bonus increases significantly.
"All employees, including those in information systems, are responsible for our HEDIS scores. Our HEDIS graph tells us the goals and where we are at the moment. If we need one more person to hit a certain percentile, the staff start looking for that person and getting them the services they need. We've created a team environment where everyone in the company works to get the members the care they need," he says.
The company's new facility in downtown Detroit will soon have 40-inch computer monitors placed throughout the building that show the health plan's performance on HEDIS measures in real-time.
"No matter where staff are, our performance on the HEDIS measures will be right in front of them. We constantly remind our employees of how important these measures are," he says.
The health plan offers bonuses from $15 to $100 to providers on top of their normal Medicaid reimbursement if they take care of preventive services for members. When a physician's office logs into the health plan's managed care system, the same big red "H" appears if the member is missing one of the HEDIS measures.
Members also receive incentives for completing recommended preventive care measures. They include gift cards, gas cards, and phone cards. Last year, Health Plan of Michigan sent more than 3,200 incentives to members.
The health plan's outreach team makes welcome calls to new members and conducts a preliminary health risk assessment. If the mini-assessment shows that the member may be at risk, the member is automatically referred to case management using the health plan's information systems "to do" list to generate a reminder on the case manager's daily task list.
"The providers who treat our patients can see everything we can internally and they have the ability to add information to our system. For instance, if we don't have a member's diabetes listed, the doctor can enter the information and send a referral to disease management," he says.
In order to improve HEDIS rates by providing timely outreach messages to members, the health plan implements regular telephone campaigns on a daily basis to remind members of the tests and screenings they need.
Initially, every staff member made the outreach calls to members.
In 2006, the health plan implemented an automated dialing system integrated with its information system to maximize the number of outbound calls member services staff can make in a day and reduce the time staff spend on wrong numbers or no answers.
"The system increased our ability to reach members by 240% in one year. The staff made more than 108,000 telephone calls in 2007 to remind members of preventive services," Lauzon says.
After the system was implemented, the health plan's HEDIS scores increased by an average of 8.6 percentage points per HEDIS measure.
If a person answers, the member services representative talks to him or her about having the preventive measure. If an answering machine answers, the system leaves a message asking members to call. If they don't call back in a week, members receive another call.
The system is set up so that if claims data indicate a member who receives a reminder call hasn't received that preventive service in 90 days, the member is placed back in the system to be called again.
This system saves lives, he adds. For instance, one woman hadn't received a Pap smear for some time and received outreach calls and reminders from the health plan.
"She was resistant to seeing a gynecologist but she finally went because we kept calling her. She found out she had cervical cancer and was able to get treatment in time. Our outreach efforts saved her life," Lauzon says.
When members enroll, the health care system stratifies them according to their risk, using historical data provided by the state of Michigan.
Members who are most severely at risk for a health care event are referred to case managers who work with them to help them get their condition under control and become compliant with their treatment plan and medication regimen.
During the initial call, the case manager conducts a health risk assessment that helps him or her develop a plan of care.
"Our system ties in the subjective information from the health risk assessment with the objective information from claims data. Having comprehensive information on the screen helps the case manager work with the patient," he says.
When a member's condition improves, he or she is moved to disease management and receives reminders about recommended care and examinations. If their condition worsens, they are referred back to case management.
The health plan has accurate telephone numbers from about 40% of its membership, and concentrates on getting the other members' contact information up to date using various methods, Lauzon says.
"We realize that our members are a transient population and hard to reach. Our MCS is available to providers in all settings, including physician offices, emergency rooms, outpatient facilities, and hospitals. This gives us access to updated contact information through our authorization and claims systems," he says.
The plan has been successful in getting in touch with members by sending a letter asking them to call the health plan with updated information. It gets other telephone numbers through database services, physician offices, and vendors, such as diabetes vendors that provide supplies to the members.
"If we don't have a good number for a member, we don't waste the nurse case manager's time in trying to contact them. That member goes in the 'lost member' campaign until we get a number for them. Then they go back into case management," he says.
When members are at risk, the health plan case managers go the extra mile to see that they get treatment.
For instance, one member with diabetes, chronic obstructive pulmonary disease, and other comorbidities was hospitalized over and over but wouldn't follow up with her primary care physician or comply with her treatment plan.
The health plan paid for a home health physician to go to her house and assess her condition.
"She weighed 400 pounds and could hardly walk because she had a gangrenous infection in her foot," Lauzon recalls.
The patient was hospitalized, and then treated at home by a physician twice a week for a few weeks, followed by weekly visits from home health nurses and intensive case management.
"We kept her out of the hospital for over a year," he says.
By using state-of-the-art technology to ensure that members receive preventive care measures and rewarding staff, physicians, and members when the preventive services are rendered, Health Plan of Michigan has increased its membership dramatically and is ranked No. 10 among the Nation's Best Health Plans by U.S. News & World Report and NCQA.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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