Modern Cardiovascular Programs Cut Costs, Inpatient Days, and Deaths

MANAGED CARE March 2009. ©MediMedia USA

Harvard Pilgrim Health Care has striven methodically to become superior in cardiac care. Its numbers tell the story.

Lola Butcher

Contributing Editor

The statistics for cardiovascular disease and stroke can seem overwhelming: 1 in 3 American adults has at least one type of cardiovascular disease; more than 1.2 million will have a heart attack this year; and 795,000 will experience a stroke.

Cardiovascular disease, which accounts for more than 30 percent of U.S. deaths, is expected to ring up direct and indirect costs of $475 billion in 2009, far more than any other disease category.

But another statistic — the death rate from cardiovascular disease declined by more than 26 percent from 1995 to 2005 — gives health plans something positive to focus on. The grim reaper that is cardiovascular disease can be fought successfully.

That’s what Harvard Pilgrim Health Care (HPHC), a not-for-profit plan covering more than 1 million members in Massachusetts, New Hampshire, and Maine, has focused on for most of this decade — and with good effect.

The rate of emergency room visits and inpatient stays for cardiac events for Harvard Pilgrim members fell from 3.31 per 1,000 members in 2000 to 2.29 in 2007; the national average was 3.5 cardiac events per thousand or greater for each of those years.

HPHC has been named the No. 1 health plan in the country by the National Committee for Quality Assurance for the past four years. Lydia Bernstein, the plan’s director of clinical programs, discussed the programs that are helping Harvard Pilgrim brandish a sword against heart disease and stroke.

Prevention and DM

Through its Healthy Returns worksite program, Harvard Pilgrim sends nurses and health educators to offices and factories to help plan members lose weight, stop smoking, and lower their blood pressure. The program, which is purchased by employers, offers financial incentives to workers who reach their goals.

Now in its fifth year, Healthy Returns has racked up some impressive results: 75 percent of participants with a body mass index reduction goal achieved their weight loss; 81 percent of those with a blood pressure goal were successful; and 76 percent of smoking-cessation participants quit tobacco.

Harvard Pilgrim’s cardiac disease management program targets members with cardiac diagnoses who are identified through insurance claims. Nurse care managers contact patients by telephone to do a clinical assessment, set goals, and develop a care management plan.

“Depending on the patient’s acuity level, they will follow up in two weeks, or three months, or six months,” Bernstein says.

The program, in which more than 90 percent of eligible members participate, is responsible for Harvard Pilgrim’s success in reducing ER visits and inpatient stays related to cardiac emergencies, Bernstein says.

Harvard Pilgrim puts members who have vascular disease or who have had a heart attack into a registry. Twice a year, those members are given a cholesterol fact sheet and a reminder about the importance of getting their cholesterol checked regularly.

The health plan also sends its primary care physicians a list of their cardiac patients and the date of their most recent low-density lipoprotein test. The goal is to encourage the physician practices to contact patients who are due for the test and to persuade them to have the test done.

Starting this year, every patient who receives a new prescription for a beta blocker receives a mailing reinforcing the message that the medicine must be taken for the rest of the patient’s life.

P4P programs

A pioneer in the pay-for-performance movement, Harvard Pilgrim awards bonuses to physician practices based on their Healthcare Effectiveness Data and Information Set (HEDIS) scores.

The program, adjusted each year, is based on several measures. This year’s program includes “cholesterol management for patients with cardiovascular disease.”

Bernstein declined to reveal how much money the plan devotes to its P4P initiatives, but she says HPHC uses public recognition to add an extra incentive for top performance. Physician practices that exceed the national 90th percentile performance on at least 8 of 10 preventive and chronic care HEDIS measures are named to the plan’s physician group honor roll, generating good publicity for the doctors and an invitation to an awards ceremony in their honor.

Honor roll

Similarly, Harvard Pilgrim names network hospitals to an honor roll if they rank among the top 25 percent on the performance measures reported on the Centers for Medicare & Medicaid Services’ Hospital Compare Website, which include 12 heart-related measures, and on Leapfrog patient safety measures.

To encourage physician practices to improve the quality of care they deliver, Harvard Pilgrim annually awards grants to support initiatives that help manage chronic diseases, increase the use of health information technology to improve patient care, or reduce disparities in patient care.

“Some of the projects have been to increase cholesterol screening and LDL control in patients of cardiovascular disease,” Bernstein says. “There was a grant to improve cardiovascular disease prevention and treatment in primary care. And there were a number of practices that have focused on reducing health disparities, including in the treatment of cardiovascular disease.”

The health plan provides physicians and nurses who serve as consultants to the grant recipients, helping them to meet their goals. At the end of each year, the grant recipients share the lessons learned from their initiative with other practices in the Harvard Pilgrim network. Now in its ninth year, the quality grant program has distributed more than $11 million to more than 140 initiatives since its inception.

Medication management

Harvard Pilgrim operates two medication programs designed to improve health outcomes for its patients, with particular attention to those who take warfarin, often prescribed to prevent blood clots in patients with certain cardiovascular conditions.

Medication safety: Because patients on chronic warfarin should have blood tests at least every 28 days, the plan notifies their physicians if the tests are not being conducted on schedule. All patients on chronic warfarin also receive educational mailings reminding them of the importance of the monthly tests.

Medication reconciliation: After a 2004 pilot program found that many recently hospitalized patients were at risk of adverse drug events because they were taking their medications improperly, Harvard Pilgrim implemented a medication reconciliation program throughout the system. Pharmacists and nurse care managers work together, using an electronic medical record, to make sure newly discharged patients are not prescribed medications that are likely to interact with one another. Within three days of a patient’s discharge, a nurse calls each patient to determine whether the patient is taking medications as prescribed. If problems are identified, the nurse contacts the physician.

During the program’s pilot phase, the pharmacists and nurses identified 150 actual or potential medication safety issues — drug-drug interactions, side effects, and compliance issues — in just 241 evaluations. Many of the problems involved warfarin, cardiac medications, and statins.

About 17 percent of HPHC members discharged from the hospital in 2008 received medication reconciliation assessments, and potential drug-drug interactions were identified in 79 percent of the cases. “It shows that there is a value and a need for this type of program,” Bernstein says.

HPHC’s 80 nurse care managers have been trained to support the medication reconciliation program, and two clinical pharmacists (full-time equivalent of 1.2) and a pharmacy intern work on it. Bernstein estimates the annual cost of the program to be about $115,000, which covers the pharmacy staff time. She believes the program may save the health plan nearly $1.4 million a year in avoided hospitalizations because patients taking warfarin are better managed.

New developments in cardiovascular care

Revascularization issues

When are cardiac bypass procedures and catheter procedures appropriate? A new document — “Appropriateness Criteria for Coronary Revascularization” — gives guidance for 180 clinical scenarios that patients present to their cardiologists and that physicians present to insurers.

In a process that took more than a year, a 17-member panel of general cardiologists, interventional cardiologists, cardiac surgeons, and others scored each scenario to judge whether coronary revascularization was appropriate, inappropriate, or uncertain.

For example, the panel ruled that revascularization would be inappropriate in a patient who had plaque build-up in one or two arteries, experienced symptoms only during heavy exercise, had a small amount of heart muscle at risk, and was not taking medication to help control symptoms. For a similar patient who had severe symptoms despite taking the appropriate medication, revascularization was deemed appropriate.

The appropriateness criteria — the first to focus on cardiac treatment — were developed by the American College of Cardiology (ACC), American Heart Association (AHA), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, and American Society of Nuclear Cardiology. Three other professional societies have endorsed the document.

The first purpose for developing the document is to help physicians and patients make treatment decisions, says Gregory J. Dehmer, MD, director of cardiology at Scott & White Clinic and a writing committee member. But the developers hope it will be used in two other ways.

Physicians, Dehmer says, should benchmark their own practices against the criteria for various scenarios.

“Some cardiologists have had a fairly ho-hum response to this, saying, ‘This all makes perfect sense and that’s how I’ve been practicing cardiology for the last 15 years.’”

“But I think there will be some that will feel as though, based on what has been set forth in this document, an excessive number of their procedures are inappropriate. This sends a fairly powerful message to those individuals that they ought to reevaluate their practice patterns.”

Payers, Dehmer says, should not use the criteria document as the absolute determinant for whether to pay for revascularization. However, he says that the criteria could serve as the first cut point, meaning that a revascularization that is identified as appropriate under one of the clinical scenarios should be paid for without further question.

If the document says revascularization is either uncertain or inappropriate, the health plan would be wise to seek further justification for the procedure from the physician. Dehmer also says that health plans should use the appropriateness criteria to evaluate the treatment of members who are cardiac patients.

“If it turns out that, say, 95 percent of the people that had a coronary revascularization did so for reasons that were judged to be appropriate, I would be very satisfied,” he says. “On the other hand, if there were a large proportion of patients that were getting coronary revascularization that was deemed inappropriate, I would be very concerned.”

Free cardiovascular drugs?

Researchers at Brigham & Women’s Hospital and Harvard Medical School, with funding from Aetna, are studying whether providing no-cost cardiovascular drugs to high-risk patients increases medication adherence and reduces future hospitalizations for cardiac events.

“It would appear to be far more cost-effective to actually ensure that patients take their medicines, and therefore avoid future hospitalizations. That is exactly the question we are studying with Aetna,” says Elliott Antman, MD, a cardiologist at Brigham & Women’s.

On paper, Antman says, giving free cardiovascular drugs appears to be a cost-effective — and lifesaving — opportunity for health plans. Results of the randomized clinical trial will not be known for at least a year. In the meantime, Antman hopes other insurers will follow Aetna’s lead in sponsoring health services research.

“This may sound a little bit radical, but I am proposing to actually ask health plans to help plan some of the research for the important questions that we need to have answers to,” he says. “Those questions will not be answered by industry, and the National Institutes of Health is not going to be a source in the near-term future. Where else do we turn?”

New performance measures

An updated set of clinical performance measures to care for heart attack patients was introduced in December. The measures — jointly developed by the ACC and AHA — were published in the Dec. 9, 2008, issues of both the Journal of the American College of Cardiology and Circulation.

Cardiologists have been at the forefront of developing performance measures, and measures of cardiovascular care were among the first to be included in Hospital Compare (http://www.hospitalcompare.hhs.gov/ [1]), the federal government’s Website that encourages patients to monitor the care delivered at their local hospitals.

The measures reflect some of the 17 practice guidelines developed by a task force on practice guidelines — a joint effort of ACC and AHA — over the last three decades.

“We are moving more and more to guidelines that are disease management guidelines rather than specific procedure-based guidelines like the original effort with pacemakers,” says Antman, the past chairman of the task force on practice guidelines.

Cardiac & diabetes DM programs seem to have had quite an effect

Harvard Pilgrim saw its cardiac event rate start to decline after a diabetes disease management program was introduced in 2000. The health plan introduced a cardiac disease management program in 2004 and an integrated diabetes/cardiac program in 2005.

Rate of emergency room and inpatient visits for cardiac events, per 1,000 members

*Average of 29 health plans

Source: Disease Management Purchasing Consortium Advisory Council

Harvard Pilgrim not only awards bonuses to effective doctors based on HEDIS scores, but gives them public recognition as well, notes Lydia Bernstein, the plan’s director of clinical programs.