CM cancer program reduces readmissions

Proactive approach starts at diagnosis

A cancer management program helps Great-West Healthcare increase the quality of life and reduce the cost of care for people with cancer by providing support throughout the diagnosis and treatment process for patients and their family members.

The Greenwood Village, CO-based health plan began its program in 2003 in response to increasing cancer treatment costs, rapidly changing cancer treatment protocols, and variations in standards of care in different parts of the country.

"We did a number of analyses on claims data to see where case management could have a potential impact. Cancer was one of the conditions that rose to the top where we could make an impact not only clinically but from a humanistic standpoint," says Mike Norris, vice president for medical management programs at Great-West Healthcare, which serves as a third-party administrator for about 6,000 employer groups and offers re-insurance for many of its clients.

"The employer groups we contract with have employees all over the country who are diagnosed with cancer. We want them to all get care according to national standards but physicians in different parts of the country may practice medicine very differently. The program ensures that our members' benefits are utilized appropriately and that they are getting standard care," Norris says.

In the first year of the program, the rate of hospital readmissions for Great-West members with cancer fell by 17%. About 87% of members enrolled in the program reported being "highly satisfied" with it on member satisfaction surveys.

Great-West partnered with the Matria Healthcare Oncology program, formerly known as Quality Oncology, a disease management company specializing in managing care for cancer patients to create the cancer management program and rolled it out in 2003.

"When we partner with vendors, we require that the program be completely branded for Great-West Healthcare. All of our vendor partners have to feed information into our system or use our software system so we can assure continuity of care," Norris says.

The case managers are nurses with experience in oncology. They create an individual management plan based on the type of cancer, the site of the cancer, the stage of cancer, the age of the patient, and other factors.

In addition to identifying members through claims data, Great-West has trained all of its employees who talk to members on the telephone to identify people with cancer. For instance, the customer service representatives are trained to listen for specific words that may indicate that a member has cancer and to refer that member to the cancer management program.

"Historically, we pick up a diagnosis of cancer once the claim comes in but we see real value in getting involved with the members as soon as their cancer is diagnosed, rather than when they have a claim for treatment," says Joel Slaten, manager of disease management for Great-West Healthcare.

For instance, if a member calls customer service to find out if a biopsy is a covered benefit, the customer service representative can refer the member to the cancer management program.

"This gives us an opportunity to be proactive and engage the members in the program and make sure their treatment protocol is based on national clinical standards.

"Most importantly, when people hear the word 'cancer' they are frightened and have a lot of questions. It is much more beneficial for them to have access to a nurse case manager at the beginning to help them make treatment decisions," Slaten says.

When the health insurer identifies a member with cancer, the staff first make sure that the member is eligible and that the employer group participates in the cancer management program.

Then the case manager verifies the diagnosis with the physician and finds out what the physician has told the member.

"Sometimes the spouse doesn't want the patient to know that he or she has cancer or the extent of the disease. It's very important to understand how to approach an emotionally charged subject," Slaten says.

The oncology nurse case manager calls the member and explains the benefits of the program and sends the member information about the specific cancer. About 99% of eligible patients participate in the program.

"We work with the doctor on the care plan and look for alternatives for some of the expensive agents used in the treatment of cancer," Norris says.

The case managers educate the members about their disease and help them come up with questions that they need to ask their physician.

Contacts avaiable 24/7

The members are assigned a specific nurse and have access to his or her direct line. When the nurse is not on duty, the patient or family members can call a nurse line 24 hours a day if they have questions or concerns. Great-West sends a magnet to members in the program with an 800 number the member or his or her family can call 24 hours a day.

"We urge members to call the nurse when they are having symptoms. Often the nurse can help alleviate the situation without the member going back to the hospital," Norris says.

For instance, if a patient has chemotherapy on Friday and feels nauseated on Saturday, the nurse on the 24/7 line can pull up the patient record and see the discharge plan, then stay on the telephone while the patient drinks water to get rehydrated.

"We help the patients avoid the emergency department or an inpatient stay. The hospital is the last place you want to be when your immune system is compromised," Norris says.

One big benefit to the program is that patients can call a nurse with special training in cancer management at any time, even if they've just had a bad day and want someone to talk to.

"People can't do that with their insurance company or their doctor's office. Once the patient has established a relationship with the nurse case manager, the services are there for the whole family," Slaten says.

The nurses are trained in psycho-social management and can help patients and family members talk through any issues they may have. For instance, they may talk to a child who is afraid because his mother has lost her hair.

"We get tons of letters from people who have participated thanking us for the program. It makes a huge difference when someone has cancer and is afraid and just wants someone to talk to. They don't want to bother their physician with questions and problems but they can call the nurse for help and support," Slaten says.

When a member has surgery, the nurse case managers from the health plan follow them through the surgery, working with the hospital's case managers on utilization management. They call the patient after discharge and make sure home care services are in place and that recovery is doing well.

"We feel it's very important to have just one nurse during the entire episode of care," he says.

Primary nurse model

Great-West operates on a primary nurse model so that the member talks to only one nurse case manager at a time.

The health plan has established a hierarchy of disease, based on industry research. For instance, no matter what other disease a member may have, if he or she has end-stage renal disease, a renal disease specialist is the primary case manger.

Cancer is the next disease in the hierarchy. This means if a member is diagnosed with cancer and has diabetes or back pain or is pregnant, the oncology nurse is the primary contact.

"If a member has diabetes and is being managed by a diabetic nurse and a biopsy comes back positive for breast cancer, the oncology nurse takes over the case. They may have a three-way conference call between the member, the oncology nurse, and the diabetic nurse to share information. The member can always call the diabetic nurse but the oncology nurse is the primary case manager," Norris says.

Once the patient completes treatment, the diabetes nurse takes over again.

The program focuses on people who are in active cancer management, those who are newly diagnosed, being worked up for a bone marrow transplant, receiving chemotherapy or radiation. People stay in the program for five to seven months on average.

About 45% of people who have had cancer are in active cancer management at any given time, Norris says. "We keep the other 65% on our radar screen but do not provide direct support," he adds.

(For more information, contact Michael Norris, vice president for medical management at Great-West Healthcare, e-mail: michael.norris@gwl.com.)