Partnership improves chronic conditions
Practice stands to save up to $1.1 million a year
When their actuaries told them they could save between $750,000 and $1.1 million a year on a disease management program for patients with just three conditions, Harbor Medical Associates in South Weymouth, MA, jumped at the chance
The practice began looking at disease management programs as a way to survive in Massachusetts’s mature managed care market
"We felt like we had exhausted most of the normal strategies such as stronger case management and better cost reduction. We decided that the next generation of strategies would be disease state management. It’s not only a managed care strategy but a strategy that involved better managing of care," says Nick Cleary, MBA, chief operating officer for the 34-provider practice with seven locations in southeastern Massachusetts.
The practice looked at creating its own disease management program or purchasing an existing program and decided that the practice didn’t have the internal resources to create its own.
That’s why Cleary was willing to look at a proposal by CVS Health Connections and Pfizer Health Solutions to locate a Center for Wellness Education, a disease state management center, within the physician group. CVS Health Connections already has similar operations within its pharmacies but this was the first time the company had partnered with a physician group.
"They had studies, a care plan, outcomes measurements, and a software program to bring to our group in a strategic partnership," Cleary says.
Harbor Medical Associates decided to target its Medicare risk population, about 3,000 lives. An examination of claims data showed that the practice spent $10 million a year for institutional and physician claims for these patients and that $4 million of the cost was for patients with congestive heart failure, diabetes, and asthma.
Since any budget surplus in a Medicare risk contract goes back to the group, the practice felt that the cost of a program would be worth the effort.
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Harbor Medical Associates Economic Rationale for Disease Management |
| • 2,500 enrollees in Medicare risk contract |
| • $10 million in total claims payment in 1998 |
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• $4.6 million spent on targeted enrollees in 1998 |
| Asthma—$0.2 million |
| Diabetes—$1.7 million |
| Congestive heart failure—$2.7 million |
| Projected Savings for Calendar Year 2001 |
| Asthma—$24,000 to $50,000 |
| Congestive heart failure—$688,000 to $1,036,000 |
| Diabetes—$63,000 to $258,000 |
"Consumers are beginning to talk about quality and selecting provider organizations based on quality. Nobody is sure what this means yet but we felt this type of initiative would be a good step in collecting baseline information and measuring subsequent improvement," Cleary says.
The groups began discussing the possibility about 18 months ago. The practice negotiated an arrangement to share its savings with CVS Health Connections as funding for the project.
Before the project was begun, the staff at Harbor Medical Associates visited a pharmacy site and checked the databases and the program itself. "Because of the Stark laws, our attorneys had to spend a lot of time making sure the deal passed muster and neither organization got into trouble," Cleary says.
A nurse practitioner, a pharmacist, and a receptionist staff the center, housed at Harbor Medical Associates’ main location. A medical director oversees the program but is not always on-site.
"For us, it was a turnkey operation but we retained control over the clinical aspects of the program," Cleary says.
The practice identified 300 targeted patients by pulling up ICD-9 codes from the billing data. When the patients’ physicians approve their participation in the program, the staff invite them to a 90-minute visit. Patients are assessed by a nurse practitioner who collects baseline information on their health status.
The nurse practitioner and pharmacist review the patient’s medication and develop a care plan, which is submitted to the physician for approval.
The information is entered into Pfizer Health Solutions’ Clinical Management System software which tracks and analyzes the outcomes.
During the first visit, the nurse and pharmacist spend 45 minutes or more talking with patients about their conditions, the medications they are taking, diet, exercise, and nutrition, and answering questions
"Most patients have a lot of questions that they can’t get answered in a 15-minute office visit," Cleary says.
After the initial visit, patients continue to see their primary care physician for routine sick visits. They go to the Center for Wellness Education for follow up education and monitoring. Any changes in care are a joint decision between the physician and the staff in the center.
The program includes an intensive educational program geared to each patient, and lasts two to three months.
"There is a significant enhancement on the educational side and we feel like we are moving the patients toward a joint compact of compliance, buy-in, and understanding," Cleary says.
Many of the patients with chronic diseases are not compliant. "This type of approach gets them owning what needs to be done and improving their health and lifestyles. And by having a better lifestyle, they are less likely to be hospitalized as often," Cleary says.
The aim of the Center for Wellness Education is for the staff to spend as much time as necessary with the patients. For instance, if a diabetic has elevated blood sugar and needs to get it under control he or she may come in several times in a week.
"The staff can spend a lot more time educating. A physician may not have 90 minutes to spend with a patient," Cleary says.
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