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Plan identifies, plugs gaps in DM programs
Pilot project focuses on severely ill
At Oxford Health Plans based in Trumbull, CT, 3% of its members account for half of the plan’s medical costs.
The plan, which covers 1.6 million people in New York, Connecticut, and New Jersey, launched an initiative to identify barriers to care and close the gaps in care for its most severely ill members.
"Having a very focused and comprehensive strategy around these high-cost members can really pay off by improving quality of life, clinical quality, and ultimately financial performance," says Alan Muney, MD, MHA, executive vice president and chief medical officer for Oxford.
When Oxford analyzed data for its most severely ill members with congestive heart failure and diabetes, the results were surprising.
"When we looked at the data around our sickest members, we were fairly stunned at what we found," Muney says. "Of the patients who were the sickest by our definition, only a third had seen a specialist in the past 12 months."
For instance, among the sickest of the congestive heart failure patients, those who by Oxford’s definition needed an electronic scale in their homes, approximately two-thirds had not seen a cardiologist in more than a year.
Among diabetes patients, two-thirds of members with a hemoglobin A1c greater than 9.5% and a significant number with levels above 11% had not seen an endocrinologist in a year.
That’s why Oxford has chosen to change courses and look at what problems prevent optimum performance in their case management and disease management programs.
"The health plan has to look at barriers to optimum care, including whether the member is being treated by the right physician, whether the member is compliant — an issue that occurs even when case managers call them regularly — and what prevents members from following up with what the doctors told them they should do," Muney points out.
The company began to look deeper at what was going on at the primary care level and found that both physician noncompliance with guidelines and member noncompliance with the treatment plan were barriers to care.
"The primary care physicians would tell patients to take certain steps, but the patient would ignore the doctor’s advice. But we also noticed that the primary care physician didn’t request certain tests or put some patients on what we viewed as the correct drug," he says.
An evidence-based medicine approach to the total cost of care is the key to Oxford’s new overarching disease management program.
"This means everybody should get everything they need, but not services that they don’t need. We are looking for gaps in accountability plus trend-driven costs and evaluation," Muney says.
The company took a hard look at the cost drivers that affect the total cost of managing chronic disease.
"We wanted to determine whether high-cost procedures and other interventions were delivering the best value. We look at disease management as the sum of three major components: case manager interventions; accountability gaps, such as physician and member noncompliance; and major trend drivers within the disease," Muney says.
The company focuses on unit cost and utilization compared to guidelines to help them understand whether care is effective, he adds.
Oxford launched a pilot project a few months ago to treat the 250 sickest members in the congestive heart failure program and the 250 sickest in the diabetes program.
Before starting the pilot project, the company developed a network of specialists who are willing to take sicker members with more complications.
"Our disease management program includes not just case management interventions but identifying which are the best physicians to deal with the illness, how they perform, and what are the trend drivers within the disease in terms of procedures and services. The net result, we believe, is higher quality care as well as lower cost," Muney says.
The plan starts by identifying the highest-cost members and those who are anticipated to have the highest cost by using a predictive modeling software tool.
Endocrinologists taking care of diabetes patients are encouraged to self-certify with the National Committee for Quality Assurance program. Oxford also worked with leading endocrinologists and cardiologists. The cardiologists helped craft a best practices in congestive heart failure program.
When members are enrolled in the program, the case managers make sure they have seen a specialist. Then they drill down to find out which individuals need more interventions in one component or another.
The interventions are tailored to what is going on with each individual member.
"To some degree, basic interventions, such as lab tests and doctor visits, need to occur every so often, but a major component is a highly focused member approach," Muney says.
For instance, members with congestive heart failure are given an electronic scale and instructed to weigh themselves once a day. The results are transmitted to the case manager, who looks at the weight and decides if an intervention is warranted.
If the weight is in the pre-determined "red zone," the case manager contacts the primary care physician and the member.
What happens then is individualized to the physician’s preference and what is needed for the member, with the goal of following well-accepted practice guidelines.
Often, the primary care physician has standing orders for the member, depending on the member’s condition. In this case, the nurse may call in the standing order or the physician may prefer that the member call the office for further instructions.
"The important thing is that the intervention occurs where there is weight gain that can trigger an emergency room visit, or a hospitalization and all the complications that follow," he says. n