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Health plan tailors medical management programs to individual organizations
Data-driven program helps develop solutions across the continuum
By identifying the most costly conditions for the health plan and for specific employer groups, Regence Blue Cross Blue Shield of Oregon (BCBSO) has been able to tailor its medical management programs to fit individual organizations and bridge the gap between various components such as case management, disease management, and pharmacy management.
The Portland-based health plan started by looking at claims data for the entire covered population and by large employer groups for the most costly diagnoses. Then it used the data to target the employers for programs dealing with disabilities and conditions that affect them more than anybody else.
"What is important is that every health plan look not just at what is popular but at what is going to have the biggest impact. That’s where the data-driven piece comes in," says Patrice Korjenek, PhD, assistant vice president of health economics for the health plan.
The analysis came up with four categories that account for about half of Regence BCBSO spending — heart disease, cancer, gastroenteritis, and orthopedics, Korjenek says.
"Essentially, the information gives us clinical targets that affect the bottom line. The idea is to identify the needs of individual organizations and have all the different pieces of medical management, including case management and disease management, work collaboratively to come up with ways to intervene," she adds.
The typical insurer looks at the same hot diagnoses, such as diabetes, heart disease, and depression for its disease management and case management programs, Korjenek points out. The diagnoses are popular because they occur frequently, cost a lot, and there are gaps between the ideal treatment and the vast majority of practices," she adds.
"Until we looked at the orthopedic claims data, we would never have focused on people having back surgery. It happens frequently, but it’s not usually an acute case, so we wouldn’t have focused our disease management or care management programs on back surgery," says Annie French, RN, manager, health care management.
The same conditions that affect the population as a whole by and large affect the employer groups, but the emphasis may be different from employer group to employer group, she adds.
For instance, gastroenteritis is one condition that accounts for a high degree of cost. In one employer group, the cost may be gastroesophogeal reflux disease (GERD). In another, the high cost may be the result of employees choosing to have their appendectomies in the most expensive facility in town, she adds.
"We can look to see what is unique about each employer group that drives their health care spending," she says.
The health plan takes specific information for a particular group, looks at their health care spending, and comes up with programs Regence BCBSO believes would be a good investment for the employer.
"Using the data gives us a higher percentage of appropriate sales of our program. We are better able to match the need of our program to the specific employer groups, rather than just try to sell the programs to everyone," Korjenek says.
The disease management department takes the information on the high-cost diagnoses by employer groups and looks for opportunities for improvement and interventions each group should consider, says Sonja Thygeson, BS, MPH, manager, disease management programs.
"We take into account aspects such as average length of employment and how long their participants have been eligible for the programs. For instance, if an employer has a lot of turnover, a comprehensive disease management program may not be a good investment," Thygeson adds.
An organization with a young and healthy population probably wouldn’t need the Special Beginnings program for high-risk pregnancy but might need a program to help manage back pain, French says.
"Once we have identified a recommended program or a set of programs, we put together a detailed business case that outlines the rationale for our recommendation," she adds.
At the same time, the organization has been able to create more integrated medical management programs that bridge the gap between case management, disease management, pharmacy management, and health promotion departments.
"We are stretching the boundaries of case management. We are no longer sticking with the catastrophic, acute-care management. We are aligning with the disease management services and moving toward the middle," French says.
By using the data generated by Korjenek’s department and working closely with disease management, the case management department has been able to take a more in-depth look at the population it serves, and take a proactive approach to members whose conditions have not yet become catastrophic, she adds.
"In the past, the way we have identified members for acute catastrophic case management was to get the information from the claims data. If you wait until there is a claim, it’s too late to have a big impact," French points out.
Having comprehensive data on specific employer groups allows the company to be proactive instead of reactive, French says.
The data help the insurer identify members who are at risk early on, before they are hospitalized and need catastrophic case management.
"We are expanding the boundaries of typical case management and using more of a disease management approach," French says.
For example, French uses the data to choose which groups to approach for the Special Beginnings program for high-risk pregnancy.
"We look at the demographics of the group, the number of pregnancies they are having, and make a determination of which employer groups would be a good candidate for the high-risk pregnancy program," she says.
This way, the company can provide targeted interventions and then show the impact of the interventions.
"One of the problems we’ve had in case management is that although we know we bring a lot of value to the table, we have not had the means of proving it," French says.
In the case of the group that prefers the most expensive hospital, the Regence BCBSO representative may approach the employer group and point out that it is paying an average of $4,000 more per case to send employees to that particular hospital.
"Often the group had no ways of knowing why their costs were high. This could lead to a change in benefits. The data give us the ability to go to an employer group and be specific about why they are paying what they are," Korjenek says.
Other employer groups have a high cost because of a frequent incidence of GERD, a condition that is associated with lifestyle.
The Regence BCBSO representative may suggest a program through health promotion and education, pharmacy management, or case management to direct members to the most effective medication.
"There are a lot of medications for GERD that are highly advertised. People get prescriptions for the next version and the next version, and it can go on forever," Korjenek points out.
Case managers or disease managers can educate members that medication is supposed to be short-term and that lifestyle changes will have an effect, she adds.