General Business Issues

Health Plans Target Comorbid Patients in Disease Management Pilots

Reprinted from the June 18, 2007, issue of HEALTH PLAN WEEK (formerly Managed Care Week), the industry's leading source of business, financial and regulatory news of health plans, PPOs, and POS plans.

The Medicare Health Support (MHS) pilot to test disease management (DM) strategies among fee-for-service beneficiaries may have yielded disappointing early results that led some participants to drop out. But many insurers and DM companies still are developing new methods and fine-tuning existing tools to serve patients with multiple comorbidities.

WellPoint, Inc. is rolling out a DM program for comorbid patients on a companywide basis, concentrating on those who seem ready to change behavior. Other DM programs focus resources on nonmedical support to help resolve problems that distract members from effective self-management of conditions, and use Internet-enabled monitors to identify patient issues.

CMS launched the MHS program in 2005 to identify best practices for serving patients with heart failure, complex diabetes and/or chronic obstructive pulmonary disease (COPD). Aetna, Inc., CIGNA Corp., Green Ribbon Health, LLC — a joint venture of Humana Inc. and Pfizer Health Solutions Inc. — and five DM companies are operating pilots across the country.

The pilot puts 100% of companies' fees at risk; they must show 5% in medical cost savings to get the fees. But some participants, such as Healthways, Inc., have indicated that they have found it difficult to demonstrate savings. And some DM companies already have dropped out of the pilot, including McKesson Health Solutions LLC, which exited the program on May 31.

DM executives say these early results underscore the expense of improving the care of comorbid patients, and the importance of community integration. "One issue probably is the difficulty in reaching the population and effectively managing medical costs," says Emily Shehane, director of disease management and demand management at Blue Cross and Blue Shield of Florida.

WellPoint, Inc., which is not participating in the MHS pilot, is rolling out its comorbidity management program, ComplexCare, across the country.

The program is aimed at pre-Medicare members who are not only high cost and high risk, but who also will most benefit from intervention, says Ellen Silver, M.D., medical director for clinical product development at Health Management Corp., WellPoint's DM subsidiary. The DM program will "concentrate our resources on the folks who are really going to be motivated to make changes," she explains. The approach can help Medicare by preventing full-blown unmanaged cases from entering the program. The insurer also will work with patients to increase their motivation by using techniques such as motivational interviewing, Silver adds.

The insurer uses a predictive modeling tool called AccuStrat, which HMC developed in 2004, to review patients' risk factors. Over the next year, WellPoint will run several pilots to test new methods of finding which patients will respond the most to outreach attempts, and which are motivated to participate, Silver says.

MCOs Address Nonmedical Issues

Other insurers focus on enhancing community support for members. Deep integration in the community and an ability to coordinate a wide range of medical and nonmedical services are keys to managing a population with one or many serious conditions, Green Ribbon Health CEO Jean Bisio tells MCW. Green Ribbon serves MHS beneficiaries in central and southwest Florida.

Community resources such as churches, transport companies and home remodeling firms can support chronic care, Bisio says. For example, if a beneficiary is wheelchair bound but his or her house is accessible only by stairs, Green Ribbon workers can find agencies to fund and build a ramp, she says.

"Our average patient is 80 years old. The barriers to care these people have include safety issues, chronic pain, sleep disorders, problems eating and skin breakdown. If we can help them address these problems, it helps them focus on the self-care management of diabetes [or heart failure]," she says.

DM programs also work to identify other potential health issues during patient encounters to ensure that all conditions are being treated.

XLHealth Corp., which is running an MHS project in central Tennessee, says that when nurses treat diabetes, they also take steps to detect and prevent heart failure, depression and even falls. They ask whether patients are taking their medications or have trouble breathing, for example, Harry Leider, M.D., chief medical officer at XLHealth, tells MCW.

That company sends nurse practitioners to nursing homes to assess quality of care and to see that patients are doing well. XLHealth also uses biometric monitoring equipment that funnels data about the patient to the lead caregiver. The company provides patients at high risk for heart failure an Internet-enabled scale that logs the patients' weight and records their answers to health-related questions, and relays the information back to nurses who track the data.

Patients with advanced diabetes get testing equipment to detect sores, because lack of circulation in diabetes patients causes numbness, and undetected sores are a leading cause of amputations, Leider says. Medication adherence equipment prompts advanced diabetes patients to take their drugs, and returns data to the company on the patient's response to the prompt, he says.

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