Incentives help sicker patients get the kind of care they need

Plan collaborates with physicians

When Trumbull, CT-based Oxford Health Plans set out to improve care for its sickest members with diabetes and congestive heart failure, it collaborated with primary care physicians and specialists to come up with a plan of care.

"We chose a very collaborative approach by involving the specialists in those areas of care in focus groups and holding focus groups for our primary care physicians to assess whether our intervention strategies were going to be acceptable to both sets of doctors," says Alan Muney, MD, MHA, executive vice president and chief medical officer for Oxford.

The health plan created a best practice network of physicians to treat the sickest patients with both diagnoses.

"We decided that the sickest members in both diabetes and congestive heart failure should see a specialist at least once a year and have a care plan that is sent back to the primary care physician," he says.

The plan began to track when the primary care physician did not appear to be following guidelines and created a set of member interventions to deal with issues of noncompliance.

A financial incentive plan that rewards specialists who treat the sickest patients is at the center of the program.

"These patients are sicker for a variety of reasons and we’re asking specialists to take care of them, so we reward them financially, beyond what they would get for a regular visit, for taking the extra time to care for these patients," Muney said.

The plan identified a subset of specialists it determined would be best for the sickest patients to see. For instance, physicians who complete the National Committee for Quality Assurance self-certification for diabetes care were chosen to treat the diabetes patients.

There is no self-certification program for congestive heart failure. In that case, the health plan aligned with cardiologists from a major academic medical center to create indicators that Oxford can use to assess who is practicing appropriately and using the best set of prescribing patterns.

The disease management staff work closely with the members’ primary care physicians to keep them in the loop.

"We know the relationship between members and their primary care physicians, and we work within that sensitivity," he says.

When a patient isn’t compliant, an Oxford representative approaches the primary care physician and asks him or her to work with the health plan to help get the member back into better control of his or her condition.

When Oxford identifies the targets for the disease management program — the people who have the highest risk of generating the most cost — the case managers first identify whether they’ve seen a specialist.

"We engage the primary care physician with the data and get their permission to interact with the members," Muney says.

When the case managers talk to the members, they support the primary care physician’s treatment plan. They tell the members that they had discussed the member with the doctor and that the doctor wants to make sure they see a specialist. The plan tracks the results, such as lab test results and number of hospital and emergency department visits.

The plan’s physicians often have one-to-one conversations with the primary care physicians.

"The goal is to have the end results roll up into a definite improvement in the bottom line in terms of the total cost of care and doing the right thing for the member," Muney says.