AHIP Coverage (Nov/December 2007)
Complex Care Management a Plus for Patients
By Andrew Halpert, M.D.
It’s well-known that seriously ill patients account for a disproportionate share of overall health care costs. Many individuals with clinically advanced illnesses, such as late-stage cancers or degenerative neurological conditions, can also suffer multiple comorbid diseases, making care in these cases some of the most expensive to manage.
The affected population is not insignificant: Approximately one out of 1,000 commercially insured individuals is identified as a complex patient, and it is estimated that there are five to 10 times such individuals in the Medicare population. Many of these patients must coordinate their care from multiple providers and frequently face challenging psychological, social, and financial realities.
Recognizing the increasing numbers of members with clinically advanced illnesses, Blue Shield of California initiated a pilot program in 2003 that created an intensive care management intervention that would provide extended support and help reduce the cost of care without compromising the patients’ health or life span. BSC worked with ParadigmHealth, an integrator of care and disease management services, to design case management interventions that extended support beyond typical care coordination and arrangement of services. In addition, BSC evaluated this program using a best-in-class study design, seldom employed by health insurance.
More comprehensive than usual case management interventions, patient-centered management (PCM) assigns highly trained nurses to provide extensive patient education and care coordination as well as pain and end-of-life management support. PCM is initiated when the nurse visits the member at home to conduct the initial assessment. There is frequent phone follow up to develop an extensive, focused, member-specific care plan. PCM helps patients select services, consider different treatment options, and avoid unnecessary hospitalizations and emergency room visits, in essence changing some patient behaviors and environments that could impair care or yield unnecessary expense.
To evaluate the effectiveness of this program, researchers from Carnegie Mellon University conducted an 18-month study that followed 756 Blue Shield of California HMO members who were diagnosed with late-stage illness, most frequently oncologic conditions. Approximately half the members were entered into the PCM program while the other half (the control group) received usual care via the same HMO delivery system. The study results indicated that the PCM program was quite successful: hospital admissions decreased by 38 percent, through more effective home care services; per-patient costs were reduced by more than $18,000; and 92 percent of the patients registered very high satisfaction rates. The findings were published in the February 2007 issue of the American Journal of Managed Care, one of the first studies to quantify actual cost reductions that result from participation in this type of expanded case management program.
According to Carnegie Mellon’s Latanya Sweeney, Ph.D., the study’s lead author, the program results were very positive. In addition to fewer hospitalizations, the PCM participants had a 22 percent increase in home care and suffered fewer treatment complications, such as nausea, anemia, and dehydration, than patients who received services through usual case management. After being provided with reliable information that allowed them to make personal choices based on their individual circumstances, many cancer patients in the PCM group opted for more conservative therapy rather than further chemotherapy or radiation treatment (42 percent less chemotherapy than the patients in the group receiving usual care). The PCM group also had 62 percent more days in hospice care than the usual care group.
About the Study
All participants had access to the same benefits, provider network and HMO-approval process. Approximately half were assigned to a group that received usual case management (UCM), which included traditional coordination of services, approval processes, and utilization management practices. Those designated for the PCM program received all UCM services with additional support that included access to a registered nurse (RN) care manager, RN team manager, and physician in active clinical practice. Care management RN interaction included home visits and an average of two or more weekly member calls, depending on the individual’s needs. Each PCM participant also worked with a care manager to develop a series of goals focused on understanding the disease state and treatment options, pain and symptom management, family and living environment, provider support, and end-of-life decision making. PCM services were provided by ParadigmHealth.
The registered nurses chosen to manage this program maintained minimal case loads (approximately 20 to 23 per RN), which afforded them additional time to be more attentive to their patients and become familiar with their specific needs. Interventions ranged from helping members more closely follow their physicians’ treatment plans, including taking medications at recommended intervals and eating recommended foods, to inquiring about any symptoms or side effects they might be experiencing, such as nausea and dehydration. Depending on members’ responses, nurses could follow up with physicians so that adjustments could be made to treatment regimens as needed. Case managers also helped members access all of the covered products and services they required, such as arranging for referrals to specialists or obtaining durable medical equipment.
Positive Results
Among the study’s findings:
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Members participating in the program had 22 percent more home care visits than those in the control group.
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The number of days spent in hospice care was 62 percent higher for individuals enrolled in the program than for those in the control group.
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Eighty-nine percent of program participants said it had improved their quality of life. Ninety-six percent said it provided a useful service, and 92 percent said they were extremely or somewhat satisfied with the program.
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The number of emergency room visits among program participants was 30 percent lower than for members of the control group.
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There was no difference in life span between the PCM and UCM cohorts.
Patients had fewer hospital days and emergency room visits, with care shifting to less costly home care and hospice settings when appropriate. The study concluded that PCM effectively reduced overall costs by 26 percent.
The average combined utilization cost of the PCM cohort was $49,742 per patient for the 18-month study duration, compared with $68,341 in the UCM cohort, which average savings of about $18,599 per patient. After accounting for the additional cost of the program, the return on investment was 2:1.
An Outlook for PCM Programs
The results of the initial Complex Care Management program pilot in the commercial sector are very encouraging—utilization costs in complex patients were reduced through patient education, coordination, and support without sacrificing life span or patient satisfaction. Based on the results of this study, BSC made the program available to its entire commercial membership starting in January 2005, and expanded it to include our Medicare population in 2006. (Results of that expansion program should be available in early 2008.)
Buoyed by the positive outcomes indicated above, Blue Shield is taking the next steps to more broadly address the complex needs of our members and the rising cost of health care. At present, we are focusing efforts on a similar pilot for members with advanced chronic diseases with high comorbidity but who have lower clinical severity and less care domain needs than individuals in the existing PCM program. Conditions are primarily respiratory, endocrine, heart and neoplastic diseases, as well as a diagnostic mix of patients with complicated acute diseases.
Andrew Halpert, M.D., is senior medical director, Network Medical Management at Blue Shield of California.
