by Jack Hurley
Vice President of Sales
“It seems like 10% - 20% of our health plan members are driving the vast majority of plan costs.” You’re probably right! Chronic disease affects one in ten Americans and accounts for 70% of the dollars spent on healthcare each year. Compounding the problem is the fact that nearly half the people with chronic disease are not receiving the care required to keep them in optimal health.
Since the mid 1980’s utilization management companies have done a good job of controlling inappropriate medical delivery and costs. While significant savings were being generated by such services as Pre-Hospital review, as well as other programs, a very important part of the population was not being addressed in a proactive manner.
For the most part plan members with chronic diseases such as diabetes, asthma or heart disease did not receive attention until the person was hospitalized, had surgery or ended up in the ER. A big reason this population did not receive significant attention was the lack of sophisticated, cost effective, risk identification tools necessary to identify the incidence of the chronic conditions in a health plans population and identify gaps in care. These tools are now available and are the first step in managing chronic conditions.
Health Risk Assessments (HRAs) are a good tool for identification of plan members with chronic conditions. Web-based HRAs can be completed easily and should provide the member instant feedback on identified risks, as well as educational links to help manage the risks. Group reports can help identify preventable risk in the plan population taking the HRA. Full participation by plan members is crucial to getting an accurate picture of chronic conditions. In addition, HRA data is self-reported and is subject to the knowledge and candor of the member taking the HRA.
Predictive Modeling in my opinion is the most effective identification tool. Ideally an initial analysis of two years of eligibility, pharmacy and medical claims data is conducted. Monthly data updates should be conducted to identify new members with chronic conditions and monitor the progress of existing members.
There are several good predictive modeling software systems available. The preference is given to the system which best identifies chronic-condition members, as well as captures those not in compliance with nationally accepted standards of care. Good predictive modeling will also identify those participants who are moving toward a chronic state or a catastrophic condition that can be referred to other care management programs.
Once the “at-risk” population is identified two management models are available. The first is an “opt-in” model. Members are notified that this service is available and given the appropriate contact information if and when they choose to participate. The philosophy is that people will comply when they are ready. Non-responding members are usually “closed” with no further action.
The other school of thought favors the “opt-out” model. I personally favor this program approach which engages all members identified with a chronic condition through a series of mailings and phone calls. Individuals contacted receive an in-depth assessment and are placed in a health coaching track or an educational track. The health coaching track works best when specially trained Registered Nurses are utilized. Members with chronic conditions often have other health conditions that require the expertise of nurses and physicians rather than a trainer or health educator. Those that are not quite ready to get into a health coaching program are placed on an education track. The educational program should provide members the standards of care for their condition as well as educational material that will help better manage their specific condition, and offers the opportunity to participate in the health coaching management program.
The goal of a good Disease Management program should be to increase member compliance with national standards of care. Remember that approximately half of all individuals with chronic conditions are not receiving the care they need to stay healthy!
Disease Management programs, unlike case management or other utilization management programs, take a bit longer to establish a return on investment. They are more of a marathon effort versus a 100 yard dash. Allow a period of 18 to 24 months to demonstrate cost savings in hospitalizations, surgeries and ER visits associated with the chronic conditions. As a matter of fact, outpatient and pharmacy costs could spike up slightly in the short term since people are now seeing physicians when they should and taking the medications required for their condition.
You could say that Disease Management is actually an investment in future savings and a healthier more productive life for employees. I recall a county commissioner saying to me at a seminar, “I wish that we had done this three years ago.”
I would submit that the time to implement a Disease Management program is now, rather than regretting inaction years from now.
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