Physician engagement pays off for DM firm 

Team inputs data for patient files 

When QMed contracts with a health plan to manage its coronary artery disease, heart failure, or diabetes population, the Laurence Harbor, NJ, disease management firm does more than just rely on claims data to come up with a treatment plan for members identified for disease management.

The company also sends a team of specialists into individual physician offices to extract data from the patient files of members identified for the program, often coming up with clinical information and medical histories that aren’t available from the insurance carrier. This gives the disease management company a more complete picture of the total patient and his or her health care needs.

"An employer group on average switches carriers every three years. The health plan’s database may not have all the patient information that the doctor has in the patient chart. By accessing the chart, we can include information and patient history that occurred years ago," says Robert Mosby, vice president for corporate strategy and government affairs at QMed.

When a health plan contracts with QMed, the vendor uses its proprietary software program to perform a thorough analysis of claims to identify which patients should be in the program.

For instance, patients identified for the coronary disease program are those with a history of heart disease, those with potential coronary artery disease (such as those with a positive stress test or with a family history of the disease), and those at risk. At-risk members include males over 45 and females over 55 who have two or more risk factors such as family history, high cholesterol, hypertension, diabetes, or smoking.

The software also cross-references the patients’ primary care physicians and creates a list of each physician’s patients.

"We then go to the physician with a description of the program and a listing of the patients who could be enrolled in the program. We ask them to sign off on the program and to reach out to their patients and help get them enrolled," Mosby says.

Getting the physicians to recommend the program is far more effective than having a company spokesman call a member, he adds.

"A doctor recommendation is a powerful way to get members enrolled in the program," he says.

After patients sign up for the program, the QMed team gets the permission of the patient and physician to include information from the patient’s charts in the company’s database, where it is combined with administrative claims data to create a complete picture of the patient’s medical history.

A team of specialists visits each physician’s office, extracts information from the patient charts, enters it into a laptop computer, and sends it by a secure data line to the company’s database.

Using proprietary algorithms, QMed takes the data and generates a set of specific recommendations for each patient based on patient data and lab information in the chart and taking into account the age, race, and sex of the patient.

QMed then sends the physicians evidence-based recommendations specifically tailored for each of their individual patients, based on best practice guidelines and information from the patient chart.

"We give evidence-based best practice recommendations and update them regularly. We’re giving the primary care physician a tool that represents the best recommendations from an expert system," Mosby says.

The database includes information from the health plan’s pharmaceutical formulary, enabling the company to generate specific drug recommendations for that particular patient in accordance with the formulary of that patient’s health plan.

"Our program reduces the variation of practice and the primary care level," Mosby says.

The company operates a call center staffed by nurse case managers who call the members at intervals determined by risk stratification. Members are assigned to an individual case manager in hopes that the two will develop a bond, Mosby says.

The nurses who make the calls are familiar with the physician’s recommendations. They motivate the members to make lifestyle changes, take their prescribed medications as directed, and comply with other physician recommendations.

"Our model seeks to engage the patient and to educate the patient with primary emphasis on motivating them to comply with the medication and recommended lifestyle changes," Mosby says.

Compliance rates for members in the QMed disease management programs are about 2.5 times the national compliance rates, he says.

In one Medicare HMO population, total population costs dropped by 17.38% after one year of the QMed program. At the same time, heart attacks were reduced by 25.8%, 60% of hypertensive patients showed an improvement in blood pressure, ischemia decreased significantly in 58% of patients, catheterizations dropped by 11%, angioplasties were reduced 5.2%, bypasses were reduced by 3.68%, and hospital admission for angina fell by 23%.