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DM program focuses on 17 conditions
Insurer saves $36 million in claims in first year
In the first 12 months of a comprehensive disease management program for members with 17 chronic conditions and diseases, Blue Cross and Blue Shield of Minnesota saved $36 million in claims, with a return-on-investment of $2.90 for every dollar spent.
The BluePrint for Health care support program provides telephone-based nurse support to members and their physicians.
In addition to providing support to members with commonly managed diseases such as asthma, diabetes, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, and end-stage renal disease, Blue Cross and Blue Shield of Minnesota’s disease management plan encompasses a total of 17 conditions.
These include: acid related disorders, atrial/fib anticoagulant therapy, chronic hepatitis and cirrhosis, fibromyalgia, incontinence management, inflammatory bowel disease, irritable bowel syndrome, low back pain, osteoarthritis, osteoporosis, and pressure ulcers.
More than 150,000 members are being served by the BluePrint for Health care support disease management programs.
"These programs help empower members with the resources to live healthier, and the 12-month data show that they are working, helping people avoid unnecessary trips to the emergency room and hospital," says Bill Gold, MD, chief medical officer and vice president for Blue Cross. "It supports doctors’ relationships with patients; members love it; and it saves on health care costs."
Blue Cross’s program reaches up to 15% of a purchaser’s health plan members, compared to typical disease management programs that reach less than 3%, Gold says.
Here are some outcomes data:
"The potential impact is staggering. This combination of conditions affects between 10% and 15% of a health plan's population, but those members typically account for 40% to 45% of all claims expenditures by a health plan," Gold says.
The members have improved their overall health as well as their compliance with recommended care plans, reports Pat Heald, RN, BS, manager of the BluePrint for Health care support program.
For instance, the members have shown an overall drop in hemoglobin A1C levels, indicating that not only are they getting the required number of tests but that they understand what they can do to improve the results.
"Members want to take better care of themselves. We know there are gaps in the health care system and providers can’t meet all the patients’ needs in a 10- or 15-minute visit. Our disease management programs are trying to address the gaps," she says.
Blue Cross and Blue Shield of Minnesota entered into a partnership with American Healthways for a comprehensive disease management program at the end of 2001 and launched programs for congestive heart failure, coronary artery disease, and diabetes in March 2002, adding chronic obstructive pulmonary disease, in April 2002, asthma and end stage renal disease in May 2002, and staggered implementation of the remaining 11 conditions in June 2002.
"It’s a big undertaking, and we take it all very seriously. Our goal is to change the way our members perceive and receive health care," she says.
The Blue Cross and Blue Shield of Minnesota program was the first in the nation to encompass such a comprehensive list of different conditions. Since many of the members have comorbid conditions, the approach allows the company to address the whole person and not just a single disease, Heald adds.
"Nobody else has ramped up and offered all these programs over such a short period of time. We have a committed team that works every single day to meet the needs of our members. We have a solid commitment from our executive leadership to dedicate the resources necessary for the program," Heald says.
The company made the decision to include the less common conditions in the program because they affect so many members.
"Our extended conditions collectively represent our largest group of members. These are conditions that are chronic in nature and very amenable to nurse education and support," Heald says.
The company chose conditions that were prevalent among their population and those for which telephone outreach could have an impact. "It was important for us to choose conditions where there are standards of care or evidence-based guidelines to support our program," she adds.
Considering the program’s benefits
Before launching its disease management programs, Blue Cross and Blue Shield of Minnesota spent considerable time deciding which program would best benefit their members.
"Our goal is to try to touch as many members with chronic conditions as we possibly can. This meant understanding the disease burden and the prevalence rate for our membership," she says.
Choosing common conditions such as diabetes and heart disease was easy because they are so prevalent, Heald points out.
"We looked at other conditions that affect a significant number of people all their lives. Our goal is that we want our members to be healthier. It’s not just the lab values that are important. It’s their quality of life and overall health in general," she says.
Before any disease management program is implemented, the care support team at Blue Cross and Blue Shield, including the medical directors, review American Healthways’ programs to make sure they meet recognized clinical standards and those of the Institute for Clinical System Improvement, a local organization of health plans, physicians, and the Mayo Clinic, that has developed standards and practice care guidelines for Minnesota.
"Additionally, we have received feedback from our network providers," she says. For instance, instead of sending reports on the members’ progress directly to providers, Blue Cross and Blue Shield of Minnesota is taking a different approach — they send the reports to the members and encourage them to share the information with the provider.
"This is in keeping with the program's philosophy that the fundamental interaction in health care is between the patient and his or her physician. Everything else in the health care system exists solely for the purpose of improving the value of that interaction," Heald explains.
Providers don’t necessarily view getting reports on their patients as a benefit because they either don’t have a system in place to incorporate the reports into their daily practice or they don’t have the time to look at them, she adds.
"Based on feedback from many of the network physicians, the health plan worked with the provider advisor council and decided try something a little different," Heald says.
The plan has educated the physicians about the disease management programs and notifies physicians when a patient who could benefit from the program has been identified. The physicians, in turn, often refer patients into the program.
"Our providers have started getting more and more involved because they understand the impact that the disease management programs can have on the members and how these programs can actually enhance the relationship they have with their patients," she adds.
The disease management nurses collaborate with Blue Cross and Blue Shield’s in-house medical case managers and behavioral health case managers, who manage the patients with complex, acute episodes of care.
When a case manager identifies a member in need of case management and that member also is participating in one of the disease management programs, the member remains in the program but his or her acute and complex illness or hospitalization may be handled by a case manager who coordinates with the disease management nurse, Heald says.
"We have certain internal triggers that prompt the care support nurses and our case managers to recognize situations in which it would be beneficial for the member to be comanaged by a disease management nurse and a case manager," she notes.
For instance, if a member is hospitalized for a heart attack, experiences severe complications, and is newly diagnosed with diabetes, the case management department would be called in to handle the acute episode of care and would facilitate the member being entered immediately into the disease management program.
"We want to make the relationship between case management and disease management as seamless as possible and as integrated as possible," Heald says.
There are about 130 nurses at the Blue Cross and Blue Shield of Minnesota call center. They work in teams, each focusing on a specialty area, such as diabetes of congestive heart failure. Within the team, patients are not assigned to a specific nurse but instead have access to a nurse specialist seven days a week.
The center has a clinical information system that brings up the patient file when a patient calls in or a nurse calls a patient. The system automatically shows what conversation took place the last time the patient spoke with a nurse and what goals were agreed upon.
"The nurse doesn’t have to start over with the patient. They begin the conversation where the previous one left off. The members feel like the person they are talking with knows them, and that is one thing that makes these interactions so successful. It is imperative that a channel of trust is established with our members," Heald explains.
The members are identified for the program by claims data, using algorithms that screen by condition for requirements that need to be met before the member is eligible.
The company sends an introductory letter to the members who have been identified, telling them to expect to get educational material on their condition and a telephone call from a care support nurse who will fully explain the program.
"It’s an opt-out program. If the members choose not to participate, they call us and let us know," she says. When the care support nurse talks to the member, he or she asks if the member wants to participate and gets permission to share the information with his or her physician.
The care support nurses conduct a series of assessments with the members to determine their level of understanding of their condition and their readiness to change. Based on their conversations, the nurse and member establish goals to help the member reach his or her optimal health and ability to manage the condition for the long term.
They conduct an initial assessment that stratifies members according to the severity of the condition and current needs. After each care call, the nurses can change the member’s stratification level.
If a care support nurse determines someone is in a position to need more help, he or she can override the stratification and arrange for the member to be called as frequently as every day. The stratification level specifies a minimum number of calls during the month.
The system restratifies members every month. For instance, if a member is hospitalized, his or her stratification level is raised and the member goes into the call queue more quickly. Changes in a member’s condition signal the need for more support, Heald points out.
In later calls, the nurse determines how much the member understands about his or her condition, whether he or she is ready to change, and the level of involvement the member has with the providers.
"The nurse and member work together to understand what the physician has told the member to do or not to do," she says.
The nurses contact the physicians directly if they identify a need that isn’t being addressed. For instance, if a member tells the nurse he’s falling down a lot, the nurse will work with the provider to get an order for a home health evaluation to determine the safety of the home environment.
"We are really focused on what the member needs. The guidelines are there, and we want them to be adhered to, but the member really drives the interventions we do and how we interact with our members," she says.