HMO touts DM programs from outside vendors

Contracting provides expertise in short time

When UCare Minnesota initiated its disease management programs, the Minneapolis-based HMO decided to use outside vendors instead of developing its own programs in-house.

The HMO has more than 100,000 members throughout Minnesota and serves Medicaid and Medicare members.

The HMO chose to use outside vendors rather than creating its own disease management programs because of the difficulty of creating a program and finding the expertise to staff it in a short time.

"We didn’t have the in-house expertise or the capacity to have the type of thorough program we were interested in. The ability to build specialized disease management programs in a reasonable time is a major obstacle to health plans," says Craig Christianson, MD, medical director for state public programs.

One of the HMO’s most successful programs is UCare Asthma Action, a disease management program for asthmatics administered by Matria Healthcare, an Atlanta-based disease management company.

The HMO is in the midst of completing a rigorous analysis based on claims experience, but quality of life surveys and a member satisfaction survey have had positive results.

"We often wait six months or more before receiving claims from hospitals. We’re hoping that we will find significant reductions in hospital stays," Christianson says.

Members responding to quality-of-life surveys have reported reduction in missed days at school and work, he adds.

Asthma is a significant problem among UCare Minnesota’s Medicaid population, particularly the inner-city population.

The asthma program went live in November 2000. There are 894 members enrolled in the care management portion who are actively managed by nurses in the call center. About 1,500 other members in the education-only program receive targeted mailings throughout the year, Christianson reports.

The UCare Asthma Action Program was one of eight UCare Minnesota programs spotlighted by The American Association of Health Plans (AAHP) in its national report "Innovations in Medicaid Managed Care: Health Plan Programs to Improve the Health and Well Being of Medi-caid Beneficiaries."

The HMO chose Matria because its asthma management program already had experience in serving the Medicaid population, Christianson says.

The Matria program is conducted in conjunction with the National Jewish Medical and Research Center in Denver. The center, originally a respiratory disease hospital, has specialized care managers who call UCare members in the asthma management program.

"The case managers at National Jewish do exactly what we would do for the patients if we have the capacity to do it in-house," says Mary Deering, RN, MPH, manager of disease management for UCare Minnesota.

The case managers at National Jewish Medical and Research Center work closely with the UCare case managers to manage complicated cases.

"Members are not necessarily aware of the split. The UCare Asthma Action program is designed to be a seamless system of care for the member," Deering adds.

Here’s how the program works:

Matria identifies likely candidates for the asthma program using claims data and other information from UCare. Once the participants are chosen for the program, the National Jewish Medical and Research Center staff takes over.

The Asthma Action case managers do a thorough assessment of each participant and stratify them based on their severity. They make sure the members have an asthma action plan in place, send them a peak flow meter, and encourage them to measure their peak flow, to learn to recognize what triggers their symptoms, and to work with their physicians.

If a member’s disease warrants it, the UCare case managers arrange a home visit by a home care nurse who does an environment assessment and makes recommendations for changing the home environment or provides patient education in the home.

The home care nurses are on the staff of home care agencies selected by UCare and were trained by National Jewish Medical and Research Center, who sent a nurse to Minneapolis to conduct the training.

The disease management case managers offer training and educational materials to physicians, including information on appropriate asthma management medications, and operate a free physician consultation line that physicians can use if they have a problem case.

"One of our initial concerns about using an outside vendor was involving a third party in the mix between provider and member. We haven’t had any complaints from the providers," Christianson says.

"The program is attractive to members as well as to physicians," he adds.

As an adjunct to their case management program, young UCare members with asthma are eligible to participate in a summer camp sponsored by the Minnesota Chapter of the American Lung Association.

The program has been available free for UCare members for some time, but interest has increased since the Asthma Action disease management program began.

"The number of members who took advantage of the program this year has doubled or tripled. It’s a fun place for the kids, but they also learn how to manage their asthma, and it reinforces what we teach them throughout the year," Deering says.

The HMO uses an outside vendor for its end-stage renal program and has a congestive heart failure program that is jointly operated by an outside vendor and a network clinic.

The company uses an outside source for telephone calls to its pregnant members.

"We are trying to help identify early on the risk factors that can affect the outcome of a pregnancy. With Medicaid patients, identifying the problem is often delayed to the point where we see adverse outcomes," Deering says.

The outreach calls are handled by the outside vendor, but the UCare case managers also communicate with the patients.