General Business Issues

Featured Health Business Daily Story March 6, 2009

Health Plans Use a Variety of Strategies to Identify and Ensure Compliance Among Diabetics

Reprinted from HEALTH PLAN WEEK, the industry's leading source of business, financial and regulatory news of health plans, PPOs and POS plans.

By Michael E. Carbine, Contributing Editor (mcarbine@aispub.com)

With diabetes affecting 24 million Americans and costing the economy close to $180 billion last year in medical and other costs, health plans say they are taking a fresh look at their intervention strategies and implementing new approaches to identifying and then helping people with diabetes manage their conditions more effectively.

But health plans interviewed by HPW say that the problem goes beyond helping diabetics manage their disease. "One-quarter of those with diabetes don't even know they have the disease," says Deneen Vojta, M.D., UnitedHealth Group's vice president for clinical innovations. "We also know that about 57 million people are pre-diabetics and that the majority of them are unaware of their risk." Compounding the problem, she says, is the fact that about 60% of people with diabetes don't follow their self-management regimens, often because of the personal costs involved. "We have no choice but to get control of this situation on the front end."

On Jan. 15, United announced the launch of its Diabetes Health Plan with built-in preventive care incentives. As a value-based design, the plan eliminates copayments for many of the out-of-pocket expenses that discourage many diabetics from effectively managing their condition.

"We know that only 40% of people with diabetes follow the American Diabetes Association (ADA) prevention and treatment guidelines," Vojta says. "So we took a step back and asked what kind of an approach would encourage people with diabetes to better manage their condition." United also is targeting the substantial number of people who are at risk for developing diabetes but who are unaware of their risk.

The insurer says it conducted extensive consumer research on the plan last year, focusing heavily on the "intent-to-purchase" factor. More than 300 people with diabetes were involved in the focus groups. "If somewhere in the range of 25% of those participating say they would buy a product, you know you're doing well," Vojta says. "We achieved a 73% intent-to-purchase response rate when we explained the details."

The plan starts at the front end with a broad screening initiative to catch pre-diabetics and diabetics alike. Screening is provided in physician offices, work sites and retail clinics that United works with.

The plan then focuses on one of the major barriers to compliance: the substantial out-of-pocket expenses associated with diabetes-related drugs, supplies and physician office visits. United's plan eliminates these copays so members don't pay for certain diabetes-related supplies and prescription drugs — including insulin, statins, oral anti-glycemics and anti-depressants — and some clinician visits. Members also have free access to online monitoring and education tools as well as self-monitoring training. And they receive a customized roadmap to help them adhere to the ADA guidelines. Vojta says member savings amount to about $500 per year.

Members who follow the guidelines during their first year in the plan are eligible for continued membership in year two. Members who, for whatever reasons, do not comply revert back to their traditional health plan.

Vojta points out that the plan is participation- rather than outcomes-based, meaning that it focuses on screening, education and adherence, leaving outcomes up to the clinician. "We're not measuring how many members get their hemoglobin levels down. We're focusing on getting people screened, educated and connected with their physicians. Their individual physicians will drive the clinical outcomes."

Three employer clients are testing the plan this year. "We want to see how the plan resonates with employers, how compliance rates change after year one, and what factors come into play for those who find it difficult to adhere to the ADA guidelines," Vojta says. She adds that United will implement a broader market rollout of the plan in 2010.

Aetna Takes Integrated DM Approach

Aetna Inc. brought its disease management (DM) program in-house in 2006, and substantially redesigned it to focus on managing individual members across all of their health conditions rather than focusing on disease silos. "This is a useful approach for members with diabetes," says Sherry Brodeur, Aetna's head of program design and sales support for national care management, "because people with diabetes typically have other health conditions." She notes that Aetna's program manages more than 30 different conditions, "and when one member has several of them, as diabetics typically do, we manage them all for that individual."

Once members with diabetes (or at risk of diabetes) are identified, Aetna begins by assessing their readiness to change and identifying their personal concerns and needs. "Every person looks at his or her own health status in a very personalized way," Brodeur says. "So we use a motivational interviewing approach based on Prochaska's Transtheoretical Model of Behavior Change to determine where the person is in terms of their readiness to undertake a change in their behavior." The next step: addressing the member's self-identified concerns and goals. "If an obese person identifies weight as the most important concern, then we address weight management, exercise, perhaps nutrition. And we use this as a gateway to diabetes intervention," she explains.

Brodeur says that Aetna's outreach and intervention strategies are highly tailored to each individual. "We found out that what doesn't work [with these programs] is for us to go in with a prescribed set of questions and approaches. As a result, Aetna approaches individual members "where they are in their lives and how (and when) they want to be approached rather than doing this from Aetna's standpoint." The program also is closely linked with Aetna's quality management-tied initiative to ensure that member and provider concerns are addressed.

HCSC Targets Obesity as 'Gateway' to Diabetes

Health Care Service Corp. (HCSC) says it is using obesity as a gateway for its diabetes intervention and management initiative. The company, which operates Blues plans in New Mexico, Oklahoma, Texas and Illinois, began pilot testing a special early chronic disease intervention program targeting Metabolic Syndrome (Met-S), a precursor to obesity, in January 2008. Its new Blue Care Connections Lifestyle Management Program, which HCSC pilot tested in 2006, refined in 2007 and launched last year, also focuses on obesity as a condition that substantially raises the risk of morbidity from diabetes and other chronic conditions.

"We reach out to anyone who has been identified through a health risk assessment or other means as obese or at risk of obesity for intervention," Joe Smith, senior supervisor for HCSC's enterprise lifestyle management program, tells HPW. Anyone with a body mass index (BMI) over 25 is flagged for outreach. "If it turns out that the member has diabetes, that member is considered to be a high-priority case," he adds. The program also reaches out to those identified as being at risk for diabetes. Members are then assessed by a clinical coach and a determination made as to whether the member should work with a coach or a nurse. Members are also evaluated using the Prochaska readiness-to-change scale.

Once in the program, members work with their coaches to create care plans and start using the tools they will need to understand their condition and comply with their care plans. Smith says that the coaches typically work with members for an average of nine months, although they can extend this for another two or three months before a case is "closed." HCSC tracks members on an ongoing basis and flags anyone who relapses. "We will reach out to those members and re-enroll them in the program," Smith says. "But the goal is to give members the tools they need to take an active role in their health and successfully manage their diseases."

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