AHIP Coverage (July/August 2006)
Disease management programs improve quality of care for Medicare beneficiaries struggling to control chronic illnesses
By Mari Edlin
Meet Sally, a typical Medicare beneficiary. She is likely to see several doctors—on average 14 a year with almost 40 office visits, according to Partnership for Solutions—and take as many as 10 medications at a time. Like almost a quarter of all beneficiaries, Sally suffers from at least five chronic conditions, a population which accounts for 68 percent of all Medicare expenditures says the Centers for Medicare and Medicaid Services (CMS). And she just signed up for the new prescription drug benefit under Medicare Part D.
Sally’s new drug plan employs many of the same tools and techniques that it has long used with its employer-sponsored health insurance plans—formularies, tiered cost-sharing, step therapy, generic substitution and prior authorization. The challenge is to make sure Sally gets the right medications to manage her multiple chronic conditions.
When she was previously covered under her employer’s plan, Sally participated in a care management program. Now that she is eligible for Medicare, she could have opted for similar services through a Medicare Advantage plan. But, like most beneficiaries, Sally chose Medicare fee-for-service (FFS) where disease management is not typically a reimbursable expense.
But the tide is turning. As Medicare Advantage (MA-PDs) enrollment increases and adds new prescription drug coverage, and as stand-alone prescription drug plans (PDPs) open their doors this year to millions of Medicare beneficiaries, more seniors than ever before can take advantage of managed care and disease management strategies.
Pilots Take Off
To test the value of disease management for chronically ill Medicare beneficiaries, CMS initiated a variety of demonstration projects and pilots. The eight-region pilot project Medicare Health Support (MHS) is a voluntary program designed to reduce risk, improve quality of life and provide cost savings in the Medicare FFS environment. “Reducing risks and costs go hand in hand. If you reduce disease complications, you can improve quality of life, avoid the services required to treat those complications and reduce costs at the same time,” says a CMS spokesperson.
Using claims data, CMS identified 30,000 beneficiaries with congestive heart failure (CHF) and/or diabetes in each of the eight regions. CMS randomly assigned approximately 20,000 beneficiaries to the intervention group and established a 10,000-person control group for each pilot. “MHS represents the first large-scale initiative in traditional FFS Medicare and one of the first randomized control studies in disease management overall,” the spokesperson says.
Randall Krakauer, M.D., national medical director, retiree markets for Hartford, Conn.-based Aetna, which includes a Medicare Health Support Organization (MHSO) serving Chicago, says the control group provides the luxury of being able to compare costs and quality against a group of unmanaged beneficiaries. “The data will be more reliable, more statistically clear and convincing,” he says, anticipating cost savings, reductions in hospitalizations and improvements in health and quality of life. “We have a tremendous opportunity to prevent critical conditions.”
Krakauer says Aetna was primed to respond to CMS’s request for participation in MHS, having already developed a geriatric care management program for its Medicare beneficiaries. The program has enrolled 17 percent of Aetna’s MA population, which is managed by geriatric and behavioral specialists and social workers.
“The MHS opportunity is a sentinel event in health care,” he says. “It is an honor and privilege to participate. It will change the way we practice and deliver health care and enable us to improve quality, resulting in savings.”
The pilots combine a holistic approach with an emphasis on self-care support, education and nurse-coordinated care management, along with 24/7 nurse phone line support, health assessments and community resources. All sponsoring organizations must demonstrate a 5 percent cost savings over a three-year period and show that beneficiaries are healthier and more satisfied with their care. The pilot will examine adherence to evidence-based care, reductions in hospitalizations and emergency room visits and avoidance of costly disease complications.
In addition to the MHS projects, Medicare Advantage plans are adopting more comprehensive disease management programs for their members, while special needs plans (SNPs) have surfaced to focus specifically on caring for the chronically ill.
Integrating Managed Care Models
“Our approach is holistic—addressing all the needs of the beneficiary, from associated comorbidities to psychosocial—while incorporating the primary diagnoses of diabetes and congestive heart failure,” says Jean Bisio, CEO of Tampa-based Green Ribbon Health, a partnership between Humana and Pfizer created to address the pilot. “Our model is community-based and provider-inclusive, one that builds a relationship between each beneficiary and a personal nurse to help effect behavior change.”
In addition to personal nurses who provide medication management, depression screenings, nutritional counseling and health support, Green Ribbon’s pilot includes 24/7 access to registered nurses; the expertise of a multidisciplinary care management team; education classes; home visits; and referrals to community resources. Information technology tools enhance coordination of care and communication. As many as 81 percent of the 20,000 eligible Medicare FFS beneficiaries designated for the pilot in West Central and Southwest Florida elected to participate.
“Our primary goal is to humanize health care for those beneficiaries who live with chronic conditions by integrating our model into the fabric of the community and by helping people make better choices about health,” Bisio adds. “If these beneficiaries can remain independent, we want them to be able to do so.”
CIGNA, headquartered in Bloomfield, Conn., is like many MHSOs in that it relies on call centers managed by nurses, “feet on the street” case managers for beneficiaries in long-term care facilities and social workers to identify appropriate community resources for its pilot in Georgia. “The complexity of comorbidities in many of these beneficiaries presents an opportunity to integrate disease and case management and to coordinate care with physicians because patients often see more than one provider,” says Beverly Everett, M.D. Eighty percent of eligible individuals have elected to participate in the Georgia pilot.
MHS pilots require both savings and quality improvement, and Everett believes the two are intertwined. “Through education, coordination of care, navigation assistance for beneficiaries and use of evidence-based information, savings will follow quality,” she says.
Doing What They Do Best
Healthways, a disease management company based in Nashville, is working with CIGNA on its Georgia pilot while also managing a second pilot in Maryland and Washington, D.C. The company has had success enrolling volunteers in its program with more than 80 percent signing up.
Healthways blends traditional disease management with case management to address the issues of polypharmacy—contraindicated and duplicate drugs—and multiple providers and comorbidities prevalent among enrollees. Healthways placed on-site nurses in long-term care facilities; developed and implemented an end-of-life, hospice component with a pharmacy benefit manager; enhanced information sharing among its staff pharmacists; and expanded the number of nurses in its markets to identify and assess problems, such as insufficient HbA1c testing and other screenings.
“Fee-for-service Medicare is the only population that we disenfranchised from disease management, and it needs it the most,” says Bob Stone, senior vice president of Healthways, who believes that the pilot will expand into more regions within two years. Since the company’s evidence-based, intervention model is consistent from disease to disease, he foresees the pilot including other disease states if there are enough members with a particular condition.
Having recently announced a merger with Healthways, LifeMasters Supported SelfCare based in San Francisco, sponsors an MHS pilot in Oklahoma and is a subcontractor for the Aetna pilot. Besides the disease management company’s participation in MHS, it initiated a CMS demonstration project in Florida for 30,000 dual eligibles in January 2005. Similar to MHS, the project focuses on CHF and diabetes, as well as coronary artery disease (CAD), and targets cost savings and quality. Cohorts are measured individually and in aggregate and thus far, savings and quality outcomes results have been positive, says Christobel Selecky, executive chair of LifeMasters.
The program comprises a significant on-the-ground component of care coordinators, community and physician relations staffs, cognitive and geriatric screenings, pharmacy management and telephonic case management. Miami-Dade County is a racially and ethnically diverse community, so the program emphasizes a culturally competent staff of local nurses, access to community services and coordination of resources such as transportation.
Derek Newell, senior vice president, client relationships, for LifeMasters, credits information technology as the backbone of the company’s disease management programs, from driving its call centers to capturing data to monitoring weight and blood pressure via phone.
Physician-Patient Collaboration
Health Dialog, a Boston-based care management company that runs an MHS pilot in Western Pennsylvania, engages physicians in its efforts to manage participants by providing educational information and practice guidelines and ensures that each patient has a health partner to speak on his or her behalf. The company calls its Collaborative Care program a “whole person, whole family” approach—one in which health coaches act as a sole contact on myriad medical issues.
In addition, Health Dialog emphasizes shared decision making that encourages members to work more closely with their physicians with assistance from health coaches. Members receive detailed information about their conditions and unbiased views about treatment options. Tamara Hall, senior vice president, service delivery, says that when patients are presented with a choice, 35 percent will choose the more conservative approach. This strategy has reduced surgeries appropriately by 20 to 40 percent.
Through shared decision making, members also are prepared to ask their physicians questions and arrive at the best solution and level of care. Health Dialog refers to these approaches as preference-sensitive and supply-sensitive care.
Hall adds that physician-patient collaboration allows Health Dialog to identify gaps in care and to apply different levels of resources and treatment intensity to avoid unwanted variations and complications (see sidebar, “Dartmouth Study Scrutinizes Medicare Spending”).
Expanding Services
Maureen Mangotich, M.D., chief medical officer for McKesson Health Solutions, says that complex care needs in the Medicare population due to comorbidities necessitate more than pure disease management. McKesson’s MHS project, which targets Mississippi, is using non-disease-specific interventions, such as reviewing patients’ medication plans and needs and addressing end-of-life planning and caregiver support issues for beneficiaries in nursing homes.
Mangotich says that Mississippi presents particular challenges: 40 percent of Medicare beneficiaries in the program are dual eligibles who struggle to pay for medications, lack proper nutrition and often suffer from depression. She says that McKesson anticipates expanding its staff to include more pharmacists, social workers and mental health professionals, as well as services to better address the needs of dual eligibles. Despite the high rate of poorer and sicker individuals in the population, McKesson’s MHS project has more than 70 percent of eligible beneficiaries participating.
Although MHS pilots do not specifically incorporate pay-for-performance measures, the participating organizations are put at risk for their programs. McKesson Health Solutions, however, has developed a pay-for-participation program for clinicians. “There is little managed care in Mississippi and a physician shortage,” Mangotich says, “so we can pay incentives to physicians for taking the time to explain the pilot program to beneficiaries, for completing a care coordination form for patients and for sharing clinical information.” McKesson plans to add performance measures to its incentive program.
Targeting Special Needs
Under the rubric of MA plans are the Special Needs Plans, dedicated to Medicare beneficiaries that are institutionalized, dual eligible or suffer severe or disabling chronic conditions. According to CMS, there are 276 SNPs operating in Medicare in 2006, with the majority serving dual eligibles. To stimulate participation, the MMA modifies Medicare’s standard enrollment rules by allowing SNPs to enroll particular populations of beneficiaries. Medicare is also phasing in a fully risk-adjusted payment to all health plans—in 2006 the adjustment for health status rather than demographic factors will affect 75 percent of health plan payments (this moves to 100 percent in 2007). By paying health plans more accurately for their sicker enrollees, the new risk adjuster will help all Medicare health plans, including SNPs.
SNPs offer a tailored package of benefits, such as supplies for those with diabetes, home environment assessments and counseling—usually richer and with less drug cost-sharing than for those in a traditional MA plan. These plans may cater to a specific disease or to the more common chronic conditions, must offer Part D and must base care management on accepted practice guidelines. “For the first time, special needs plans offer an opportunity to service a targeted Medicare population—the severely ill—and focus on chronic disease and their environments,” says a CMS spokesperson. “The plans do a better job in terms of quality than traditional Medicare for this population.”
Minneapolis-based Evercare, part of Ovations (a division of UnitedHealth Group dedicated to caring for Americans over 50), emphasizes teamwork, coordination of multiple treatments and preventive care in caring for members in its SNPs. To promote a holistic approach, members are stratified by the number of conditions, not just by disease state, says John Mach, M.D., CEO of Evercare. He says that the majority of the sicker population is in community settings, while the rest is institutionalized.
For example, management may range from preventive care and a traditional telephonic model for those with three or fewer conditions, to a nurse practitioner heading a team of health care professionals who work with a nursing home’s staff, to a care manager who works with the family to coordinate medical and social support services to keep enrollees as independent and healthy as possible. Mach says that Evercare leverages family and community resources and the expertise of social workers and long-term care staff in treating higher-risk patients. The care management program has resulted in 50 percent fewer emergency room visits and hospitalizations. Mach believes that SNPs’ success will be defined in part by their ability to effectively reach and serve culturally diverse populations.
Passport Advantage, University Health Care’s special needs plan based in Louisville, primarily focuses on COPD, CAD and diabetes. The disease management programs combine a one-on-one relationship between a case manager and a high-risk patient with traditional population-based approaches. Nurses provide counseling, education and referral to appropriate services, which are supplemented by mail and Web materials.
Passport Advantage also tackles the practitioner side of the equation by sharing names of members who would qualify for disease management programs; supplying information about members’ hospitalizations and emergency room visits, screenings, comorbidities and compliance with medications; and providing practice guidelines.
"Repetition and patience are the order of the day with this demographic group,” says Terry Watson, manager, health management for Passport Health Plan. “A one-on-one education approach is probably the most effective, but the staff requirements and costs associated with staffing typically mean that one-on-one efforts tend to be focused on those with the most advanced health issues.”
A Promising Start
SidebarDartmouth Study Scrutinizes Medicare SpendingThe Dartmouth Atlas Project, conducted by the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, sent a ripple through the health care system, having found that as much as 30 percent of Medicare hospital spending on chronically ill seniors may be unnecessary and may fail to improve the quality of care provided to beneficiaries. The study also revealed considerable variations in hospital care, and showed that hospitals that treat patients more intensively and charge Medicare the most do not get better results.The project studied 4.7 million Medicare enrollees who died between 2000 and 2003 and had at least one of 12 chronic diseases. About 30 to 35 percent of Medicare dollars is spent on this population during the last two years of their lives.In addition, the project found that most acute care hospitals have become first-line providers of services to chronically ill Medicare beneficiaries when care could be better managed, safer and less expensive if provided outside the hospital setting—in a home health or hospice setting, for example.The study concluded that if all providers managing the care of people with severe chronic illnesses during the last two years of their lives met the benchmarks of high-quality providers, Medicare could reduce spending by at least 30 percent and could improve medical care. |
Having combined its commercial and Medicare disease management programs under one umbrella several years ago, Health Net of California got a head start when it developed its MA plans—an MA-PD, a regional MA PPO and a plan for dual eligibles. Addressing asthma, diabetes, chronic obstructive pulmonary disease, CHF, CAD and depression, the programs are population-based and identify members in need of disease management by analyzing drug and medical services use; stratifying them by risk; and proactively targeting them with appropriate care, says Lance Lang, M.D., medical director for Health Net, based in Woodland Hills.
Key to all programs is patient education disseminated via the Web, “snail” mail, telephone calls and 24/7 health coaches. In both 2004 and 2005, the health insurer reduced hospital admission rates by 9.6 percent. Lang attributes improvement to assisting members in making the right health care decisions.
CDPHP has provided disease management to all of its populations for conditions such as asthma, diabetes, CAD, heart disease and pulmonary conditions for more than 10 years. According to Sheila Hoorwitz, manager, disease management, wellness and appeals, the Albany, N.Y.-based health plan recently enhanced its efforts with an innovative, free program offering 24/7 access to a personal health coach. CDPHP’s Medicare Choice members receive this benefit as well as SilverSneakers, a national fitness program designed exclusively for older adults, and case management assistance with issues ranging from transportation and delivery of medications to access to community resources, physicians and social workers.
Michael Burke, director of government programs for CDPHP, attributes part of the MA program’s success to the shift toward risk adjustment, which pays the health plan a higher rate for individuals with more comorbidities. This creates a financial incentive for the health plan to invest in more than basic medical management and introduce comprehensive disease management approaches and innovative programs.
Disease management has proven a fruitful approach for improving quality of care for patients with chronic conditions in a variety of populations. Increasingly those same doors are open to Medicare beneficiaries.
Mari Edlin is a freelance health care journalist living in Sonoma, Calif.
