Disease management pays off for insurer
Plan saves on medical costs for chronic illnesses
A comprehensive disease management program has netted savings of 6% to 7% of medical costs for the conditions included in CIGNA Health Care’s Well Aware disease management program.
The program, with more than 500,000 participants across the country, has resulted in a reduction in medical costs and an improvement in quality outcomes. For 2003, CIGNA estimates a 15% reduction in hospital admission rates for diabetics, a 16% reduction for members in the cardiac programs, and an 18% decline in admissions for those with asthma.
CIGNA Health Care, with headquarters in Bloomfield, CT, started its disease management programs in 1998. It currently has programs in diabetes, coronary artery disease, asthma, congestive heart failure, and low-back pain.
"With chronic conditions as a leading cause of illness and death, we want to help our members achieve and maintain a high quality of life," says Pam Mays, MPH, BSRN, RN, assistant vice president for care management.
The company has a collaboration with American Healthways, a disease management vendor based in Nashville, TN.
"While we contract with a vendor, it’s very much a CIGNA program. We are responsible for program design, identifying members for inclusion, integrating with other medical management programs including case management and behavioral health, and for clinical and financial outcomes," Mays says.
Once a member is identified as eligible for the program, the health plan sends them a letter inviting them to participate and giving them a number to call if they decline to participate. Only about 2% choose not to participate.
Participants and their primary care physicians receive information that familiarizes them with the program.
After the patients are enrolled in Well Aware, an American Healthways nurse calls, welcomes them to the program, performs a general health assessment, and answers any questions.
"The American Healthways nurses support the Well Aware program through proactive outreach," Mays says.
The programs are customized to fit the needs of the members. The intensity of the nursing intervention varies by program and is customized to the individual member.
The CIGNA program takes an integrated approach. Patients with more than one chronic disease are enrolled in both programs, but one disease management nurse addresses all their problems and coordinates all their care.
"We don’t want our patients who have diabetes and congestive heart failure to be called by two nurses. We want it to be as streamlined as possible, with one nurse looking at all the clinical information and spearheading the goal-planning process," Mays says. "The overlap is significant between cardiac disease and diabetes."
About 30% of all coronary heart disease patients also are diabetic. This makes it important for the member to receive education about both heart disease and diabetes, she points out.
Throughout the disease management process, the American Healthways disease management nurses work with the CIGNA case managers when patients’ conditions become exacerbated.
In addition to managing disease, Well Aware helps members better cope with their chronic illnesses. Because of the high prevalence of depression as a comorbidity of chronic illnesses, the nurses do a depression screening that the health plan developed in conjunction with CIGNA behavioral health.
"Someone who is depressed is less receptive to learning. The disease interferes with compliance and can present a barrier to care," Mays says.
If the disease management nurse determines that the patient is at risk for depression, she gets patient consent, notifies the patient’s primary care physician, and helps support the patient through depression management, Mays says.
The nurse tells the member she is going to conduct a depression screening and asks if she can share the information with the primary care physician.
If the screening is positive for depression, the member is put on a higher stratification level to receive more intensive disease management, including more frequent follow-up calls.
If the member has behavioral health benefits through CIGNA, the disease management nurses also can connect a member with a CIGNA behavioral health specialist.
The nurses establish a rapport with the members when they do the health assessment and depression screening. They work with the member to establish individual goals for self care.
"We try to provide the kind of information that people can use in their everyday lives and that they can help with their discussion when they meet with their physicians. We help them understand what they hear from their physicians and to understand their condition and improve their overall health," Mays says.
The goal of the program is to teach members to be more informed health care consumers so they can make the right choices and timely choices, Mays says.
The health plan examines its patient databases on a monthly basis, using pharmaceutical, laboratory, and medical claims data to come up with a detailed composite of each patient for the disease management nurses to use.
The health plan data help stratify the patients. The plan looks at disease state and comorbidity and uses other clinical information to determine the risk level of the patient.
The plan examines the ICD-9 codes for dozens of different disease states and comorbidities and uses this to determine the level of outreach.
"We present the most consistent and full picture of what is going on with the patients, Mays says.
A visit from a Horizon/Mercy social worker often is the only visit that many of the health plan members get while theyre in the hospital.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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