AHIP Coverage (July/August 2004)
By Jay Greene
Health plans across the nation are forming partnerships with community organizations, collecting and analyzing members' health claims data, enrolling patients into disease and care management programs and increasing bilingual communication efforts to reach out to underserved and minority populations.
Over the last several years, many health plans have realized that developing outreach programs to target underserved populations is a key to controlling health care costs, improving quality, and providing greater value to employers, members and society, says Dan Hilferty, president and chief executive officer of Keystone Mercy Health Plan in Philadelphia. Keystone serves more than 269,000 members in southeastern Pennsylvania.
“Outreach into underserved populations has been an evolution for us and other health plan organizations,” Hilferty says. “We used to think that getting out into the community, participating in events, maybe doing giveaways for people to get to know the health plan, was all outreach was about.”
But with the numbers of the uninsured rising and access to health care services threatened by budget cuts and increasing costs, Hilferty says most managed care organizations now realize that saving money for government payers and employers also means providing high quality care to patients.
“We have to identify where our different populations exist and target the services they need,” Hilferty says. “Now we are more conscious about working with community organizations and with key leaders, and focusing on giving care to people in disease states.”
Keystone's “Healthy Hoops” program is one example of outreach to underserved communities, Hilferty says. Under the guidance and supervision of celebrity basketball coaches and medical staff, the asthma case management program includes screenings, a full-day basketball camp and a post-camp evaluation. (PHOTOS AVAILABLE)
Healthy Hoops encourages youngsters with asthma to use exercise, nutrition, inhalers and other medications to help control their condition. For example, 40 percent of participating children had emergency department (ED) visits for asthma in the six months prior to joining the program. Afterward, ED use dropped to six percent.
“It has met our expectations,” Hilferty says. “We generated a lot of excitement about it. We were serious about the carrot side of it, but just as diligent on the clinical side. A number of parents have thanked us and told us it has enabled them to be a better parent.”
Hilferty says Keystone plans to take Healthy Hoops to other health plan service areas around the country. It also plans to develop similar outreach programs for other high-cost disease states it has identified.
Outreach starts with identifying populations
Health plans like Keystone also are using their medical claims, pharmacy and lab results data along with sophisticated information technology systems to identify high cost or high health risk populations, says Stephen Wood, a principal at Reden & Anders, an Ingenix consulting firm in West Valley, Utah. Their goal is to direct the sickest or more expensive into care or disease management programs, he says.
“Advances in information technology have given health plans an important tool in serving their members, reaching out to underserved populations and reducing health care disparities,” Wood says.
Health plans have become very good at collating data and tying back the information to outreach programs, Hilferty says.
“Managed care is a data-driven enterprise,” Hilferty says. “Once we identify a population, segment (patients) by disease states (for example, congestive heart failure, diabetes, or asthma), then we can do an assessment to determine an outreach care strategy.”
But there are various cultural and practical barriers to collecting health data based on race and ethnicity. Most plans collect minority health data from their claims information or informally through other community or government sources.
A recent survey conducted by the Robert Wood Johnson Foundation found support for federal legislation to encourage collection of health information from minorities and ethnic groups that would be used to improve health care delivery and reduce quality disparities. (SEE RELATED STORY, PAGE XX)
“We look at various disease states without directly collecting race and ethnic information,” says Rita Johnson-Mills, president and chief executive officer of Managed Health Services, an Indianapolis-based managed care organization. “We find that out when we talk with membership.”
But Johnson-Mills says collecting health information based on race would be helpful in targeting disease management programs.
“If we could slice and dice the information we could put programs in place better,” Johnson-Mills says. Absent comprehensive data, MHS collects minority health information and tailors its programs through the help of a partnership with the Indiana Minority Health Coalition.
“We look at health care disparity data and the coalition provides information back to us about what the disparities are so we can determine what kind of programs should be developed,” Johnson-Mills says. “Health plans should be able to look outside their organizations for help identifying minority populations.”
Outreach through community partnerships
Some health plans that offer outreach programs to underserved populations do so either through philanthropic efforts or through partnerships with community organizations, Wood says.
“Most health plans view outreach as (the process) of identifying a population that could benefit from a product (the plan currently offers) and then using resources to get them into a disease management program,” Wood says. “But there are an increasing number of plans that are using outreach to coordinate a whole range of community services. The challenge is that it is really expensive to do on your own.”
Over the last two years, the United Health Foundation, Washington, D.C., has pledged more than $3 million in grant money to help three community health centers and their sponsors develop integrated centers of excellence to offer family-centered medical care to underserved communities.
The three centers are the Congress Heights Health Center, Washington, D.C., the Children's Health Fund's Pediatric/Family Center, Bronx, N.Y., and the Jefferson Reaves Senior Health Center, Miami.
“We continue to advocate strongly that there be an essential health benefit package for all Americans and that benefit packages be based on the best science and clinical guidance,” says Reed Tuckson, M.D., United's vice president. “In the interim, and with resources decreasing to the 43 million uninsured Americans, we have been working … to create centers of excellence in community health centers.”
Tuckson says United wants “to prove the point that poor people can receive the same quality health care as the rest of the nation. We can create centers of choice instead of centers of last resort.”
United Health Group, a Minnetonka, Minn.-based health plan, established the United Health Foundation in 1999 as a nonprofit, private foundation with a mission to support health and medical decisions that lead to better health outcomes and healthier communities.
“The money goes for expanded clinical and support staff,” Tuckson says. “The centers are reorganized into comprehensive, integrated care teams that target high-impact diseases that affect their particular communities.”
The centers of excellence approach will introduce aggressive patient and community population screening to identify at-risk persons, assist them with risk reduction activities, and provide the medical care necessary to treat their condition and prevent long-term complications, Tuckson says. Care teams will focus on a variety of chronic diseases and conditions, including diabetes, hypertension, asthma, depression, HIV, sexually transmitted diseases and arthritis, depending on the community's needs.
“You start with community outreach that is culturally sensitive for people who are at high risk,” Tuckson says. “These people are not often coming to the clinics because of perceived barriers to the care system.”
Another health plan that is very aware of health care disparities is the Chinese Community Health Plan, a 25,000-member plan in San Francisco. Formed to address a large underserved Asian and Hispanic population, the core of CCHP's mission is to reach out to minority populations, says Richard Loos, its chief executive officer.
“To do outreach right you have to identify your population and communicate with them and offer products and services to meet those needs,” Loos says. “We live in a society that has a lot of diversity, and health plans need to be proficient in understanding cultural differences if they want to provide quality health care.”
Recently, CCHP began working with LifeMasters Self-Supported Care, a disease management firm based in Irvine, Calif., to recruit Asian case managers to increase cultural competency in care management approaches. Enrollment and retention rates in disease management programs have dramatically improved, Loos says.
“We turn LifeMasters' health care education material into Chinese language,” Loos says. “It is very important for the outreach people to speak the language of the members and to be able to be accepted by the patients they reach.”
Another partnership intended to increase outreach effectiveness is the “Airwaves” program, a joint effort between the Health Alliance Plan in Detroit and six local elementary schools.
The Airwaves program is designed to educate children with persistent asthma to recognize, manage and alleviate asthma triggers in their environments, says Tommye Hinton, RN, HAP's associate vice president of health management services. HAP serves 535,000 members. Some 300 children participate in Airwaves.
“Typically health plans don't provide services outside their walls,” Hinton says. “Our outreach approach is a school-based asthma program targeted to a large underserved African American population of children ages 6 to 11 years old.”
Hinton says HAP first assessed the prevalence of asthma in children in its own health plan membership and then used state health data to identify larger market needs.
“There is an epidemic in Detroit,” she says. “Asthma also causes more school absences than any other chronic disease.” The rate of asthma in children in Detroit is 18 percent compared with the national average of seven percent.
HAP also plans outreach efforts to address diabetes, cardiovascular disease, and depression, Hinton says.
MCOs like Managed Health Services (MHS) and Health Services for Children with Special Needs, a Medicaid MCO in Washington, D.C., have found that partnering with community organizations has expanded their ability to reach underserved populations.
“Our outreach has evolved as we have grown as a company,” says MHS' Johnson-Mills. Founded in 1995, MHS operates a Medicaid program with 125,400 members.
MHS offers a variety of outreach programs to underserved or ethnic communities. For example, MHS participates in the annual Indiana Black Expo Health Fair and provides free health screening tests and dental evaluations. To increase rural access, MHS also has provided grants to renovate a federally qualified health center to increase examination rooms, expand pharmacy services and open a dental clinic, Johnson-Mills says.
MHS also participates in Festival 500, an annual community event in May that precedes the Indianapolis 500 car race. MHS staffed a health screening tent and conducted educational sessions, including programs on healthy eating, treatment for diabetes and pre-natal care. (PHOTOS AVAILABLE).
“We are hiring Hispanic outreach staff to better respond to questions from our Hispanic population,” Johnson-Mills says. “We have materials available in Spanish. Language can be a big disconnect. We need to help members understand the importance of seeing primary care doctors before they get sick.”
Educating patients or caregivers is an important aspect of outreach, says Cecil Doggette, director of outreach services for Health Services for Children with Special Needs.
Twice a month Doggette leads the MCO's “Parent Advocate Leaders (PALS) Support Group,” which provides a forum for parents to talk about the vast array of services for special needs children that sometimes overwhelm and confuse low-income families, Doggette says.
“Outreach is the foundation of getting information to the grassroots community about the programs you have available to them,” Doggette says. “We contact people by doing health fairs, calling them on the phone, visiting them in their home, and developing groups and resources to help support people with special needs.”
Providing funds to encourage health care visits also can be a powerful ally in improving outreach services. For example, the Highmark Caring Foundation, a subsidiary of Highmark Blue Cross Blue Shield, Pittsburgh, is making $1 million available in the form of $100 vouchers per person for health care services.
Highmark's voucher program is part of a state effort in Pennsylvania to offer basic medical benefits for adults ages 19 through 64 with incomes below 200 percent of the federal poverty level and who are ineligible for medical assistance.
“Our responsibility is to do outreach and eligibility determination for (a variety of low-income health programs,” says Charlie LaVallee, executive director of Highmark Caring Foundation.
Participants in the program have diabetes, hypertension, congestive heart failure, heart disease and heart attacks at rates at least twice the national benchmark rate, LaVallee says. The voucher program works through a partnership with community health centers and rural health clinics.
“We target the uninsured and go about it with a coordinated strategy,” LaVallee says. “We work with community partners … schools, food pantries, churches, social organizations. We work with anybody and everybody in the community.”
Highmark also is sponsoring a pilot program to screen for hepatitis C virus in a partnership with Nuestra Clinica Education and Prevention Services, a Lancaster, Penn., community health group.
“One portion of our coverage area (Lancaster County) has a high percentage of Hispanic population that is threatened by hepatitis C,” says Holly Plevyak, a Highmark spokesperson. “Research shows Hispanics are at a greater risk of contracting hepatitis C than other ethnic groups.
From January through April 2004, 116 people received screening tests and 42 tested positive for hepatitis C. Those testing positive received counseling and referrals to physicians and pharmaceutical programs, Plevyak says. “More than half came back for follow-up treatment,” she says.
Here are a few other examples of health plans or managed care organizations that have reached out to underserved populations within their memberships or in their communities to improve clinical quality, reduce costs and provide greater customer service.
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Regence BlueShield, Portland, identifies Spanish-speaking children who have not received sufficient numbers of well-child visits and immunizations. Their parents are contacted to remind them that visits are overdue.
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In a public-private partnership, the state of Florida's Agency for Healthcare Administration and LifeMasters developed a disease management approach to serving Medicaid beneficiaries with a primary diagnosis of congestive heart failure. More than 8,000 beneficiaries have enrolled in the program. During the first two years, the state saved an estimated $12.6 million, which amounts to a 16 percent health cost savings.
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To address health care disparities and language barriers, Health Net, Los Angeles, staffs a cultural linguistics services department to improve responsiveness to members, outreach associates, and network providers.
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In 2003, Tufts Health Plan, Boston, awarded more than $250,000 to six non-profit organizations to provide homelessness prevention as part of a statewide effort to address the cause of homelessness.
“We have found out two things with our outreach programs,” LaVallee says. “The uninsured is not one population. There are the short-term and the long term uninsured. We also learned that people sometimes need to hear about programs four times before they apply. We are committed first to working at grassroots level with groups to make the programs known, but also to try to dispel people's fears. Most people don't like to be part of welfare. This effort protects their dignity.”
