Disease Mangement

Health Plan Disease Management Enrollment Techniques Are Evolving Rapidly

Reprinted from the March 3, 2006, issue of INSIDE DISEASE MANAGEMENT.

Health plans, faced with the fact that the vast majority of people who are asked to enroll in a disease management program will resist, are tackling the problem with a combination of tenacious, carefully scripted phone and mail contacts, publicity, and high-tech efforts such as automated telephone calls that then transfer the member to a nurse.

But these efforts are an uphill battle, especially in commercial populations, where people have less time to participate. And both Medicare and commercial plan members often are very suspicious of calls purporting to come from their health plan, DM executives say.

Given all the factors involved, about 90% of people contacted to join a DM program will resist enrollment, says Karen Johnson, manager of case management and disease management at Providence Health Plan in Portland, Ore., which covers about 235,000 people overall.

"In today's climate of identify theft, it's very difficult to convince someone over the phone that it's OK to talk about personal stuff — especially if it's coming from their insurer," Johnson says. "They think, 'If I tell you this, you'll have the ability to affect my coverage.'"

Also, some people who have been diagnosed with chronic diseases don't want to talk about it or consider how it affects them, says Johnson, who adds that "their way of dealing with it is not to think about it." And many people are simply too busy to consider adding another task, she says.

The issue of enrollment difficulties was highlighted early this year when PacifiCare Health Systems, Inc. announced it would end its HeartPartners Medicare DM demonstration project effective Feb. 28 — 10 months ahead of schedule — because of problems enrolling enough beneficiaries.

But it goes well beyond the problems with HeartPartners — which Gordon Norman, M.D., former head of DM at PacifiCare, says were inherent in the demonstration project's design — to issues inherent with DM in general: the reluctance of patients to let strangers into their lives to direct their health activities.

In the HeartPartners PacifiCare demonstration project, the health plan said it was terminating the program early because ultimately enrollment was only about 25% of the 15,000 enrollees that PacifiCare and its partners, Alere Medical Inc. and QMed Inc., had hoped for in 2003, when the program began. Only about 3,750 enrollees were active in the program as of January 2006, although more than 8,400 had enrolled over the program's life span.

The goal of the demonstration project was to enable CMS to assess whether DM programs, along with outpatient drug coverage, can improve medical treatment plans, reduce hospital admissions and cut costs. Norman, who moved to Alere as executive vice president and chief medical officer when Alere acquired PacifiCare's entire DM operation last June, says there were serious problems with enrollment that were related to the way the demonstration was designed.

First, he says, there's no underestimating the importance of good contact data, which he says CMS initially didn't provide. Even with the use of commercial services that link names and addresses to phone numbers, PacifiCare could get good phone numbers for only about 50% of potential enrollees on the list, Norman says.

Then there was the issue of informed consent — because HeartPartners was a demonstration project and therefore was an experiment, PacifiCare initially had to get people to sign a detailed "legalese-filled" consent form, Norman says, adding that so many potential enrollees balked that CMS eventually waived that requirement.

All in all, the HeartPartners project provided many good lessons about what not to do that have been applied in the new Medicare Health Support (MHS) pilot DM programs, he says. "A better job of advance PR needs to be done with the beneficiaries," says Norman. "That's the way the Medicare Health Support programs are being done — [the organizations in the pilots] are not cold-calling these people. The people expect the call" because they've received mailings and because the programs have gotten so much publicity.

Early results from MHS indicate that more than 100,000 beneficiaries now are participating, according to CMS. That represents nearly a 63% participation rate; more than 160,000 beneficiaries have been invited to participate in the eight programs, which began operations between August 2005 and January 2006.

Norman says the strong opening shows the value of advance publicity for the program with both Medicare enrollees and physicians.

Cold-Call Suspicions Run High

Still, Medicare beneficiaries can be easier to enroll than commercial members, although both groups are likely to be suspicious of a cold call, says Johnson. To combat these problems, Providence, which has DM programs for coronary artery disease, diabetes, congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease (COPD) and cancer, has developed a protocol of first contact for people identified with a chronic illness, Johnson says. "We're very careful to send out an introduction letter, and then call people within a week or two weeks maximum after they've received the letter," she says.

In the past, Providence didn't have enough staff members to make those calls promptly, and consequently lost opportunities to enroll people because they had forgotten what the letter said when a nurse finally called up to two months later, Johnson says. Adding the staff members to make the calls promptly has been "very, very helpful" in aiding enrollment, she says.

Then, if a member rejects the offer of help through DM with a comment of "I already know everything about the condition," the nurses are trained to respond, "Well, then, would you like to be kept up-to-date with the newest developments?" says Johnson. "Sometimes this will hook certain people," she adds.

In addition, in May 2005 Providence changed its scripts so that the enrollment calls were more interactive, Johnson says. Overall, "we've taken the approach of making it conversational, with not so many questions," as questions can put members on the defensive, she says. "We've broken down some of the rigidity. Since we've changed that, we've been a lot more effective in getting them to engage."

Different diseases call for different approaches, Johnson says. Members who have diabetes and coronary artery disease may be younger and have less time to chat with a nurse on the phone, whereas members with congestive heart failure and COPD "actually enjoy having a longer conversation." Therefore, the health plan tailors its approaches to each disease.

Success rates in enrolling people through phone calls has been running about 40%, Johnson says. About 2,300 members — 1% of Providence's overall patient roster — are active in DM programs, she says.

Constant tweaking and re-evaluation have been key in making enrollment efforts more effective, Johnson says. "We're constantly looking at our programs and ourselves and how we are doing," she says. Johnson was unable to provide details of how much the enrollment component of the programs costs.

Plan Tailors Call Strategies

At Independence Blue Cross, "we've learned that repetition is important — we use multiple telephone or mail attempts to engage members," says Esther Nash, M.D., senior medical director, health management programs. "We have pretty intensive engagement efforts."

The plan, with its DM partners, also spends quite a lot of time on the quality of the enrollment data, Nash says, adding that "we've learned we can't engage people if we don't have up-to-date phone numbers and addresses." Independence uses every contact with the member as an opportunity to collect that information, and also employs vendors that work with phone lists, she says.

Independence and its vendor-partners also try to target its call strategies to the specific population, Nash says. For example, calls are placed to commercial members at various times of the day and evening, while Medicare members, who "engage more easily," can be found at home more frequently during the day, she says.

The health plan targets members who are in a "clinical decision window," as well as those who might have missed a medical test, Nash says.

Independence has found that it has "significantly higher engagement rates" — defined as people actually agreeing to speak with a nurse — if it uses automated telephony to make contact with the member, rather than a mailing, Nash says.

Automated telephony is a computerized phone call to the member; at the end of the call, the computerized voice offers the member the opportunity to transfer immediately and speak to a live coach. This usually generates an 8% to 10% response, compared with a 1% or 2% response from members who have received a mass-mailing piece that encourages them to call and speak with a nurse, says Nash, who adds that "it's dramatically different and much more cost effective than live coach calling." She won't provide specific cost figures.

Regardless of whether DM personnel are using an automated telephone system or live coach calling to reach enrollees, Nash notes that the plan and its vendors must take steps that will make people more willing to pick up the phone. "We live in a world where people use caller ID, call blocking, or use a cell phone with an unlisted number," she says.

To combat the problem of caller ID showing an unfamiliar number, Independence has worked with its information technology staff to make certain that the phone number shown on a member's caller ID device is local, and it says "Connections Program," she says. This occurs even when the call comes from a DM vendor and is not local, she says.

"Although this was not expensive, it was not technologically easy, and it was difficult to do from a phone technology standpoint," Nash says.

In addition, Independence takes every opportunity to promote and reinforce the program's value in the marketplace, including general communications with members and media advertising, she says. And besides reinforcing the program to members directly, the health plan is investing in an employer "tool kit" that will allow the plan to partner with employers to "put the word out on the Connections program," Nash says.

The next approach could be rewarding the member in some way — potentially financially — for participating in DM programs. Some employers already are experimenting with making contributions into workers' health savings accounts as a reward for participating in health programs, and this trend is likely to continue, experts say.

"To get to the next level of member engagement will mean integrating with member incentive programs," says Nash. She says that Independence has discussed these strategies internally but hasn't yet implemented specific enrollment incentives. "The mere fact of better health, living longer and quality of life is not enough for everyone," she adds.

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