HMO, PHOs collaborate for disease management

System tracks patients with diabetes, CHF

Three separate health care organizations — two PHOs and an HMO — have joined forces to design a disease management program for congestive heart failure (CHF) and diabetes. The program is a unique collaboration between St. Francis Health Network, St. Vincent Hospitals and Health System, and ADVANTAGE HEALTH plan, a statewide HMO, all based in Indianapolis.

The HMO and the PHOs have developed a disease management program that tracks patients across a number of categories. The partners plan to expand beyond CHF and diabetes to include patients with other diseases and conditions in the future. The program uses Pfizer Health Solutions’ Clinical Management System disease management software to track the patients being served by the three organizations.

"We haven’t figured out who loses. We share the expenses and have an opportunity to improve the health of members and improve their quality of life and quantity of life," says Bernard Emkes, MD, a medical director at St. Vincent’s. "In the long run, we also hope that there is decreased cost — less retinopathy and renal failure and all the complications of diabetes and congestive heart failure."

The two PHOs have contracts not only with ADVANTAGE but also with other payers. Between them, the three organizations have more than 104,000 members. Emkes and his counterpart at St. Francis, Richard Need, MD, had been talking for some time about inconsistency in treatment programs. "The physicians in our PHOs were becoming confused. One HMO sets certain guidelines, and another tells you something else," says Emkes. "We wanted to make life simpler for physicians and care more consistent to members."

The three partners decided to go in together to purchase the system from Pfizer Health Solutions. "It came down to a matter of convenience and effectiveness for the three partners to purchase the system. The cost was reduced for each, and we can bring value to a large number of patients — more than 100,000 members from three entities," he says.

The partners looked at a number of systems and chose one that allowed local control. The program is unusual because it allows each of the partners to track its own patients without having access to patients from the other entities. Pfizer Health Solutions was willing to set up segregated databases to give all the partners access to their data but not to data from other partners. For example, ADVANTAGE has access to data from all its members but can’t go into the St. Francis database for information on their patients in other plans.

The collaborative effort creates an efficient workflow and saves time spent on phone calls between the HMO and the networks, says Isaac Myers, MD, vice president of Medical Affairs at ADVANTAGE. "From a resources standpoint and a sense of time spent, it’s more efficient. I can go into the system and find answers," he says. "There is a much better flow process, and it’s more efficient from an operational side to do good case management."

ADVANTAGE has had disease management programs, but never a nucleus connecting the health plan and the networks. "We would mail information and meet the networks, but we didn’t have a tracking process in place to integrate the whole process. This ties [everything] together to make it flow," he says.

When the program began, the network sent a letter to all its primary care physicians, telling them that when the case manager calls and suggests that members come in for a visit, it’s not elective. The physicians in both PHOs welcomed the program, he adds. "We’ve reached an age where providers are getting inundated from various sources, whether it’s a health plan or a provider network. They welcome the efficiency in the process because they aren’t getting contacted by multiple sources," Myers says.

Before beginning the program, the partners identified patients who were diagnosed with heart failure and diabetes and solicited their participation in the program. Based on the information entered in the system, the software electronically prompts the case manager to call the patient at specific time intervals. She enters the information she receives during the conversation into the computerized system, which triggers responses based on the data entered.

For example, if the patient says he weighs 191 pounds and weighed 180 two weeks ago, this triggers a set of questions designed to get to the root of the problem. If the patient doesn’t know what a low-salt diet is, the system will e-mail literature to the patient or the case manager can print out diet instructions and mail it to patients. At the end of the intervention, the program generates a synopsis report for the case manager, a letter to the patient enumerating what was discussed, educational literature for the patient based on his responses to the questions, and a letter to the patient’s physician identifying areas where the patient is having difficulty.

"This clearly allows for a more focused visit. I have my agenda and the patient has his agenda, and this puts us on the same page," Emkes says. "It causes a more focused physician visit and in the long run leads to more appropriate treatment with less hospital costs."

In addition to relying on the system triggers, the case manager can add her own impressions of the patient’s condition. For example, if the case manager notes that the patient sounds short-winded, the system will prompt her to call again the next day. The fact that the program tailors the educational pieces to the membership and sends triggers to case managers is one of its strong points, Myers says. "A lot of times, you have guidelines and processes you want to follow but you forget to do certain things. The program is designed to make sure key elements are there," Myers says.