Disease Mangement

Insurers' Congestive Heart Failure Programs Add Pharmacy Tools, Broaden Eligibility

Reprinted from the May 19, 2006, issue of INSIDE DISEASE MANAGEMENT, a biweekly newsletter with timely news and analysis of financial results and outcomes for new disease management programs.

Health insurers are expanding their heart failure disease management programs to include more patients in earlier stages of the condition and add medication compliance and other pharmacy management services. Such changes, along with an ongoing reliance on high-tech devices that can predict sudden changes in patients’ conditions, are helping to improve outcomes from the programs. They have reduced hospital admissions by 29% for Blue Shield of California, and delivered an overall return on investment (ROI) of 2.7 to 1 for HealthPartners, based on pre- vs. post-intervention studies, the two insurers say.

The American Heart Association estimates that almost 5 million Americans have heart failure — previously known as congestive heart failure (CHF) — and 550,000 new cases are diagnosed each year. There is no cure for the condition, which is marked not by a sudden failure of heart function, but by a gradual deterioration in the ability to pump blood.

Insurers with Medicare Advantage and Medicaid products are particularly focused on heart failure DM programs, “since the average age of a heart failure patient is mid-70s,” says Randy Williams, M.D., a cardiologist and CEO of Pharos Innovations, LLC, a Northfield, Ill.-based firm that develops and markets patient-monitoring devices. He adds that “there’s reasonable interest within the commercial insurer environment, but it’s certainly not the No. 1 item.” Williams formerly headed Evanston Northwestern Healthcare’s heart-failure DM program.

Heart failure programs are among the oldest and most common DM programs. The biggest advances in these initiatives are improved patient monitoring and self-care programs, Williams says. Although insurers and DM firms can search for patients using medical and pharmacy claims, the key is “to have data from the patients themselves.”

That is because abrupt changes in symptoms can tip off patient managers to a sudden deterioration in the heart’s ability to pump blood. For example, a patient might report a sudden weight gain from one day to the next, or swelling in the feet or ankles, possibly indicating edema. As the heart becomes less adept at its pumping action, it returns blood from the veins to the heart more slowly, causing fluid to build up in tissues.

As a result, many heart failure DM programs incorporate a daily patient weigh-in. That type of data “wouldn’t be picked up through a monthly phone call,” Williams says.

Devices to aid in heart failure management can vary dramatically in price and capabilities, he adds. “They run the gamut from literally an implanted pacemaker-type device all the way down to simply having the patient stand on an $8 bathroom scale from Wal-Mart [Stores, Inc.] and use an interactive voice response system to input their symptoms and weight.”

He adds that sometimes, new technological advances can complicate the data-gathering effort beyond what is needed. No matter what device is used, “the thing that really seems to work is having frequent interactions with the patient. You have to spend time talking to the patient much more frequently than once a month.”

Calif. Blue Shield Adds More Rx Management

Blue Shield of California in the past six months has added more pharmacy management tools to its heart failure DM program, says Andrew Halpert, M.D., senior medical director for network medical management.

The insurer has an in-house pharmacy benefit management subsidiary that administers pharmacy services for about 95% of members, he explains. Using that inhouse resource, “we’re getting to the next level of monitoring and compliance, and looking for lapses in care,” he says. For example, the pharmacy program targets heart failure patients who aren’t on ACE inhibitors or other types of blood vessel dilators, or who have ceased filling prescriptions for such medications.

Blue Shield of California also has broadened eligibility for the program to include patients who have heart failure, but have physical infirmities that prevented them from being able to stand on a scale. What the plan calls an “electronic scale” was a centerpiece of the program, and Halpert contends that it is a substantial improvement from “the usual clinical practice, since physicians aren’t calling patients every day to ask, ‘Have you gained three kilos?’”

More likely, an unmanaged patient would have such symptoms noticed after further deterioration that triggered an emergency department visit.

Under the program expansion, if the patient can’t stand on a scale, “we would just set up a symptom box,” a screen that gathers daily patient-reported symptoms and transmits them to nurses, Halpert says.

The insurer uses vendor Alere Medical, Inc. to manage care for heart failure patients in commercial and Medicare products, which cover about 2.5 million members.

The plan is responsible for identifying patients, and uses data mining to search for a hospital admission or emergency department visit with a heart failure diagnosis in the last 12 months, two professional service claims for heart failure in the last 12 months, or five distinct pharmacy claims for diuretics. Once patients are identified, Alere is responsible for day-to-day patient management.

Blue Shield of California is preparing to release “ultimate bottom-line claims-based outcomes” associated with the heart failure DM program, Halpert says, comparing experience in the 2004 baseline year with the 2005 comparison year. “When we looked at the baseline vs. post-program [results],…one of the key drivers is inpatient admissions” for all causes, not just heart-failure-related stays. He says admissions among the group fell 29% in the comparison year from the prior year’s level — a result that did not surprise him. “It’s a pretty aggressive program,” he explains.

In addition, he notes, heart failure DM programs often can deliver immediate savings, since patients’ conditions can deteriorate so quickly. With patients enrolled in a DM program, “you keep on top of them, and then savings can happen two days later.” By comparison, he says, an asthma program might yield substantial outcomes 10 or 20 years later.

Given the significant drop in admissions, Halpert expects that the program has generated overall cost savings. He says Blue Shield of California will release the savings results in the next few months.

HealthPartners Expands Program Eligibility

Bloomington, Minn.-based HealthPartners also has expanded the eligibility criteria for its heart failure DM program, including not only more frail patients, but also those in earlier stages of the condition, says Renee Koziol, disease management program manager. The health plan now includes patients who cannot stand on a scale, or who have cognitive issues that prohibit them from operating the scale and symptom reporting technology.

In addition, HealthPartners also reaches out to patients in classes I and II of the condition, according to the New York Heart Association Classification.

Class IV patients — those who are confined to a bed or chair and have symptoms even at rest — “are pretty much guaranteed going to be on a scale and monitoring,” Koziol says. Class III patients, who have substantial activity limitations, may or may not receive daily monitoring, depending on their comfort level in managing symptoms, she adds.

Patients in classes I and II may have no symptoms or only slight limitation of activity, and are comfortable with mild exertion. HealthPartners members in these classes receive quarterly or annual nurse phone calls and educational material, Koziol says. In all, there are about 1,600 patients enrolled in the heart failure DM program, which is open to all of HealthPartners’ 642,000 members. About 300 of the patients use the electronic scale.

“For the last two years, we have been working upstream to include levels 1 and 2,” says Terry Crowson, M.D., associate medical director for disease management.

Nancy Grant, HealthPartners’ program manager for disease management, says the insurer just completed an outcomes study that indicated an ROI of $2.70 for every dollar spent on the program for commercial and Medicaid members. She says the plan also recorded a 9% decrease in hospitalization for heart failure patients. The insurer used 2003 as a baseline year, and compared outcomes to those in 2004 in a pre-post study similar to Blue Shield of California’s.

Grant says the ROI calculation includes all medical costs for the heart failure population, since “it’s somewhat hard to tease out specific costs” related to the condition.

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