Concentrate on those who will benefit the most

HMO moves to reduce cost of health care

By concentrating its disease management efforts on members who are likely to benefit most, an Indianapolis-based HMO hopes to keep its members healthier and reduce costs to employer groups at the same time.

"The bottom line is that health care costs are going up at a rate that our country cannot afford. Employers are very upset about it and are looking for ways to reduce costs. Many are considering reducing benefits, and that may be counterproductive in the long run," says John C. Ellis, MD, FAAP, associate medical director for M-Plan, Indiana’s largest commercial HMO.

"As an HMO, we believe that our members should have access to preventative care, and we do everything we can to keep everybody healthy. This will lower the costs for members and employers and improve health care overall," he says.

The plan is working with a number of different tools, some from outside vendors and some developed internally, to identify the members who are likely to benefit most from disease management interventions, the kind of information likely to work best in helping the members control their diseases, and what initiatives are most easily put into action.

Identifying high-cost patients

In addition to concentrating on members who already are experiencing high costs, the tools identify patients who are not high health care users but are likely to become so in the next 12 months as indicated by prior utilization patterns and other indicators.

These may be people who refill their prescriptions only half the time or those who have diseases that are likely to get worse with age.

"The bottom line is that we want to identify members who have a chronic disease or are at risk for developing a chronic disease and make sure they are getting the best care they can get and are as healthy as they can be," Ellis says.

The health plan chose to concentrate on the top 3% of members because they have the resources to handle that many members.

The vendors give M-Plan information in a database form easily accessible by nurse case managers. The members are prioritized by severity, and information on their specific issues is included.

"The more usable information you have, the better you are able to care for members and their health. If members are paying for their health care through payroll deductions and the employers are paying a lot for it, they’re also interested. We consider ourselves to be the steward of our members’ dollars," he adds.

An advisor group of physicians helped M-Plan design the way to approach members with chronic diseases.

Stratifying into severity groups

Once the members are identified, the plan stratifies them into severity groups. The interventions depend on the members’ severity.

"We make a lot of information available to members. Some take our advice and some don’t. For instance, we offer smoking cessation for members with asthma, heart disease, diabetes, and other conditions because smoking makes the risk substantially higher. Some are interested and some are not," he says.

M-plan makes an effort to identify the members who are interested in smoking cessation and intervene with them.

"If they are interested, we want to help them do what they need to do to be successful. Because we are stewards of the members’ premium dollars, we try not to have a big program for those who aren’t interested in stopping," he adds. M-Plan concentrates on providing resources where they will have an effect, Ellis says.

For instance, the plan offers smoking cessation programs to members with chronic diseases.

"We look at ways to provide them opportunities to take advantage of the entire program or just parts of it. For instance, if they may be thinking of stopping eventually, we may send them a mailing every month. If they are serious about quitting, we may have someone call them," he adds.

If they are not thinking about quitting and not willing to think about it, the health plan provides them some information about smoking and its effect on their chronic disease.

"We try to provide appropriate information for the members who don’t want to stop smoking to make sure they are aware of the opportunity in hopes that it may move them along the path," Ellis says.

"It’s a real challenge. Some people don’t want to be bothered at all about their smoking. We have to be very careful how we do it," he says.

The health plan has used pharmacy claims data to identify members who are taking anti-depression medication and contacts them to encourage them to comply with whatever they and their physician have decided to do, Ellis says. The plan monitors their prescription refills and if member don’t refill them, they get a telephone message reminding them that the medication should be refilled unless the physician and the member decided not to continue it.

The messages are provided by a vendor who carefully scripts them to meet the members’ needs.

"We started with reminders for physician appointments and have branched out to send other kinds of messages to our members," Ellis says. The recorded messages have been very well received, he adds. "We have sent tens of thousands of messages about depression and have had only a few complaints."

M-Plan has provided its network participants with very specific unique profiles that the health plan designed, Ellis says.

"We have a variety of methods to make sure all our physicians are aware of the guidelines, and down the road we hope to be able to monitor more carefully how physicians are complying with the guidelines," he says.

The plan gives physicians information about their practice patterns that are risk-adjusted.

"That way, if somebody writes more prescriptions than somebody else, they can’t necessarily claim their patients are sicker because that is factored in," he says.

M-Plan takes steps to make sure that physicians are aware of treatment guidelines and that the members are aware of what they should be doing.

"Overall, patients with asthma across the country are underdiagnosed, and the level of severity is estimated regularly. They aren’t treated as aggressively as they should be," Ellis says.