Higher costs and fewer dollars put a new emphasis on wellness

CMs have opportunity to make a difference

Faced with rising healthcare costs and declining healthcare dollars, providers and payers alike are putting a new emphasis on wellness and prevention, and case managers should fit right in.

The healthcare industry, long dependent on increasing the bottom line by providing more services to patients, is focusing on outcomes and keeping people out of the hospital and the emergency department, says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, case management consulting firm. "I'm beginning to see an emphasis on keeping people healthy rather than just curing them when they get sick," she says. "Case managers in all areas of practice are becoming educators in terms of providing information on how their clients or patients can take an active part in their own healthcare."

Karen J. Bray, PhD, RN, CDE, vice president, clinical care services for Optima Health, the managed care division of Sentara Healthcare, a Norfolk, VA-based healthcare system agrees. More employers are interested in preventive and wellness programs than ever before, Bray says. "It's hard to measure, but there is data that suggests that in addition to lowering the cost of healthcare, wellness programs improve productivity because employees are absent less and more engaged at their work," she says.

Because of its commitment to keeping people healthy, Optima Health has developed Mission: Health, a program for Sentara employees that offers incentives when they manage their diseases and adopt healthy behaviors. (For details on Mission: Health, see article, below). "We know that 20% of people account for 80% of healthcare spending, but we also feel an obligation to help people with risk factors, lead healthy lifestyles, and stay healthy," Bray says.

The emphasis on wellness and prevention offers opportunities for case managers, who have always tried to motivate people to do the right thing for their health, says Mary Beth Newman, MSN, RN-BC, CMAC, CCP, MEP, CCM, program manager of case management at WellPoint Centers of Medical Excellence, based in Mason, OH, and president of the Case Management Society of America (CMSA), with headquarters in Little Rock, AR. Many employers are putting initiatives into place to give employees a break on the cost of health insurance if they have blood work done, take an online health risk assessment, and engage in health coaching if it's indicated, she points out.

"Health coaching is another opportunity for case managers," Newman says. "Case management always involves educating and supporting the person and helping them reach the best level of health and wellness attainable."

Healthcare providers are going to have to engage patients in taking responsibility for their own health, Kizziar adds. "People can no longer be passive recipients of healthcare. Patients are going to have to become responsible for maintaining what level of health they have, and they have to have the information they need to do it," she says. As they work with patients, case managers should move beyond just talking to them about their current episode of care, Kizziar says. They should seize the opportunity to involve them in adapting healthy habits, she says.

Taking a holistic approach to healthcare and focusing on the entire person, not just the disease or the episode of care, is part and parcel of case management practice, Newman adds. "Case management interventions always involve education, and it should be more than just taking care of the problem at hand. Case managers should look at a person's medical, psycho-social, and environmental issues and help them [reach] the level of health and wellness that is attainable," she says.

Kizziar gives the example of a case manager working with a patient recovering from a severe injury who is a smoker. "We know that nicotine impedes the healing process and that patients with traumatic injuries and bone fractures should be encouraged not to smoke," she says. "Case managers don't have to harp on other reasons [that] smoking is bad. They should tie their message into the patient's interest, in this case that the fracture will heal more quickly without nicotine."

Newly diagnosed patients offer a window of opportunity for case managers because they are likely to be motivated to change their behaviors and take responsibility for their healthcare, Kizziar points out. On the other hand, if someone has been a diabetic for 20 years and their idea of managing it is to keep doing what they've always done, and go to the hospital occasionally to get the disease under control, the possibility of getting them to change is diminished.

There are some people who are intentionally noncompliant, who have the information on healthy behavior, comprehend it, and still make an educated decision to continue unhealthy habits.

"We have to recognize that this is a decision they have the right to make and put our focus on those who are willing to change, Kizziar says.

Healthy employees generate $3.4M ROI

Incentives reward healthy behavior

A program that provides incentives for employees to stay healthy is generating a six-to-one return on investment for Sentara Healthcare, an integrated healthcare provider with headquarters in Norfolk, VA.

The program, titled Mission: Health, offers employees the opportunity to work with health coaches if they have health risk factors and with case managers if they have diabetes, heart failure, and/or coronary artery disease. Participants may receive a discount on the cost of their health insurance and/or funds in a flexible healthcare spending account if they meet certain conditions.

Optima Health, Sentara's managed care division, began Mission: Health four years ago. The health plan also offers a version of the program to employer groups. In the second year of the program, Sentara Healthcare realized a net $3.4 million savings in healthcare costs attributable to Mission: Health, says Karen J. Bray, PhD, RN, CDE, vice president of clinical care services for Optima Health. The health plan had been experiencing about an 8% increase in claims each year among its employees. The first year, claims went up an additional 5.7% because many employees found out they had conditions such as hypertension and hypolipidemia, and people with chronic conditions who were not taking their medication started to do so, Bray says.

"The savings came into play in the second year, and we've been able to demonstrate the same kind of savings on an annual basis," she says. Costs have stayed high in pharmacy utilization, but emergency department use and hospital admissions have dropped. About 78% of employees are participating in Mission: Health, Bray says.

Every year, Sentara employees have the opportunity to sign up again for health benefits and complete a personal health profile, which involves undergoing testing for total cholesterol and HDL cholesterol, blood pressure, and body mass index. They also answer questions about tobacco use in the past 90 days and whether they exercise three times a week or more.

The health plan uses the answers to calculate the employees' health risks. Those with a risk of 0 or 1 receive a reduction in the cost of their health insurance that totals about $600 a year. Members who have a risk score of 2 to 5 have the opportunity to work with a health coach to improve their health habits. If they work with the coach at least once a quarter, they also are eligible for the $600 savings.

"We chose to include wellness in our program because we feel that we should address preventive care and wellness as well as illness," Bray says. "We know that with our chronic disease population, we spend a lot of money on a few people, but we also care about the health of all our employees, and we want the people who are healthy to stay healthy," she says.

Employees with diabetes, coronary artery disease, or heart failure are offered the opportunity to call in and be assigned a case manager who will work with them to manage their disease. "We reach out to these members, but we also require them to call in to participate. We want to inject a sense of responsibility and emphasize that this is a program in which the employees have to be involved, and not a program in which the case manager is responsible for taking care of them," she says.

The case manager performs a complete assessment that covers not just the disease but other health and psychosocial issues. The case manager then develops a care plan and a behavioral plan that the member agrees to follow. Employees are required to work with their case manager at least once a quarter, but they most make contact more often.

Members who work with a case manager earn an additional $460 deposited to a flexible healthcare spending account if they meet all the evidence-based criteria for managing their condition. For example, diabetics should see their doctor twice a year, have two hemoglobin A1c tests and an eye exam, and take their medication right 80% of the time. The health insurance company mines its data to determine if employees are filling their prescriptions. If the computer indicates employees are not filling their prescriptions regularly, the health plan asks them to prove it. Some employees have military benefits and fill prescriptions at the base. Others take advantage of flat rates for prescriptions at local pharmacies.

The case manager has the final say in whether the employee gets the incentive. "We train them to be very objective about it," Bray says. "The idea is not to make sure everybody gets the money, but to make sure they are successful in managing their disease."

Bray attributes much of the success to the financial incentives members receive for taking an active role in their healthcare. "Good health should be its own reward, but the reality is that people do what they are incentivized to do, and incentives go a long way toward getting them to participate in improving their health," she says.