Health program saves $1.70 for every dollar spent

Inpatient admissions down, member satisfaction up

A health management plan for persons with chronic conditions has generated a 1.7-to-1 return on investment and glowing responses to satisfaction surveys for Health Alliance Plan (HAP) in Detroit.

Health Alliance Plan began the HAP HealthTrack program in August 2004 with a program for heart failure and expanded it to include other chronic conditions after the heart failure component showed a decrease in hospitalization and an increase in recommended care. For instance, from 2003 to 2005, the number of inpatient admissions among HAP members with congestive heart failure declined by 65%. Use of ACE inhibitors among members with heart failure increased from 38% prior to the program's implementation to 78% in 2005. The percentage of members with LDL cholesterol levels below 100 mg/dt increased from 61% in 2003 to 70% in 2005.

In addition to the financial gains and improvement in member health, this program has enhanced member satisfaction, says Richard Precord, MSW, director of clinical care management for the Detroit-based health plan. "This year, we've had about close to a 70% return rate on our surveys," Precord says. "We have evaluated the first 117 surveys returned, and 100% of members who talked to a case manager reported being satisfied or very satisfied."

Members at high risk for hospitalization or complications from the disease work with an RN case manager, and, if indicated, a behavioral specialist or pharmacist, who helps them learn to self-manage their conditions. "We have developed a member-centric chronic care registry rather than a disease-specific registry. We approach our members holistically, rather than from the standpoint of a disease," Precord says.

Staff are cross-trained to work with members with all of the conditions in the program and attend regular in-services on the various conditions. They can call on a certified diabetic educator if needed when they work with members with diabetes. They have a high prevalence of comorbidities, Precord says. "For instance, many of our members with heart failure also have diabetes," he says. There aren't very many members who have just one condition, he says. Staff members look at all the needs and work with them on all conditions, Precord says.

Members are identified for the program by a variety of methods. The health plan automatically analyzes medical claims, pharmacy claims, and laboratory claims and values every month to identify members with chronic conditions. The computerized system also looks for gaps in care that may indicate that a member's disease is not being well-managed. For instance, the program flags members with diabetes who have not had regular hemoglobin A1c tests as well as those whose test results are outside the normal range.

The enrollment packet sent to new members includes information about the program along with the insurer's web site and a telephone number to call for more information. If the data show that new members are not managing their chronic disease well or have not had the recommended tests and procedures, they are referred to the program for appropriate intervention. Their data system also identifies members who were admitted to the hospital with a chronic disease or who have had a coronary event and been hospitalized as soon as they are discharged so that a staff member can call them, Precord says. "We also get referrals from physicians and other providers," he says.

The names of members who are identified with chronic illnesses and gaps are forwarded to an enrollment center where the staff make outbound calls to members to discuss the program and schedule them for a telephone appointment with a staff member. "There are health risk indicators for each condition that prompts a telephone call," Precord says. For instance, a member who has a high LDL cholesterol level or someone who has made a visit to the emergency department is referred.

The staff members have the member's health profile, medication, labs, and utilization data at their fingertips when they call the members. They complete an extensive assessment over the telephone and, based on the assessment and other information, the staff members identify goals and work with members to set priorities, Precord says.

In the past, the staff would get a member's name and number and then call the doctor's office to obtain clinical information, he says. They have put together a methodology to prioritize, Precord says. They are risk stratified before the nurse calls them, and the relevant clinical data are readily available to the nurse, he says. "It's a much more efficient way of doing things," he says.

Staff members frequently contact members over the first three months, then taper off the calls when the members begin to better manage their condition. Many are trying to manage multiple conditions, which can be very overwhelming, Precord says. The staff work with them on getting the conditions under control and eliminating barriers to appropriate care, he says. Since there is a high prevalence of depression among people with chronic conditions, the disease management staff may co-manage members with the behavioral health team when appropriate.

HAP staff go through training on motivational interviewing and behavioral changes so they can more effectively engage members and facilitate healthy behavioral changes. Helping to manage chronic diseases is not as simple as just calling them and telling them what to do, Precord says. Staff need to find out what motivates people to change, he adds.