Disease management

Can Self-Management Programs Ease Chronic Conditions?

In-person and Internet group programs such as the Stanford model are now available to millions, and research indicates that they work

It’s an American epidemic — 70 percent of all U.S. deaths are related to a chronic disease. Half the adults here endure at least two ever-present illnesses, according to the National Council on Aging (NCOA).

Traditionally, the focus has been on medical treatment of each condition, but the growth of the affected population calls for innovative strategies to delay disease progression, improve function, and tackle the daily problems of life with a chronic ailment.

However, a highly-respected alternative approach has been shown to save enough through reduction in health care expenditures to pay for itself — even within the first year.

It originated in the late 1970s, when Stanford University Medical School set out to create an education program to build patients’ skills and confidence in managing their own health and maintaining active, fulfilling lives. Its arthritis self-management program was designed as a participatory group workshop for people with any type of rheumatic disease. After several years of thorough evaluation and testing, it was made available to other health care organizations.

The self-management approach

Today, Stanford’s arthritis program is offered throughout the United States and in Canada, the United Kingdom, Australia, China, New Zealand, South Africa, Scandinavia, and Saint Lucia. By 1990, it was the prototype for a suite of successful self-management programs developed at the Stanford Patient Education Research Center, led by Professor Kate Lorig, RN, DrPH.

The NCOA reports that 75 percent of health care costs stem from chronic conditions. “Most health plans focus on the 2 to 3 percent of members who they believe are their highest risks, with multiple hospitalizations, for instance,” says Jay Greenberg, NCOA senior vice president for social enterprise. “Stanford self-management workshops provide a cost-effective way to reach the 20 percent to 30 percent of members with multiple chronic conditions who are not yet sick enough to be heavy utilizers. Self-management could avoid or postpone many members’ worsening so much that it’s hard to help them improve their health care. This group is where we’re convinced that we can bend the cost curve with secondary prevention. Proper self-management can bring them a much healthier life, lower utilization, improved pain tolerance, and greater functionality.”

In Stanford’s programs, a group of participants meets six times in weekly two-hour sessions in a community setting such as a library or senior center. The workshop is led by two trained lay leaders who often have a chronic condition themselves. By now, many of these facilitators are “graduates” of a self-management program.

Sessions explore a broad spectrum of crucial topics. Participants discover how to deal with specific physical problems like pain or fatigue, and with emotional problems such as frustration and depression. They learn effective exercises to maintain and improve strength, flexibility, balance, and endurance. Appropriate medication use, better sleep techniques, healthy eating, and effective communication (with family, friends, and health care providers) are covered. By the sixth week, participants have the tools and encouragement to lessen disease-related problems and make better-informed treatment decisions. At each session’s end, every participant sets an individual realistic goal, then shares progress with the other group members at the next session. Stanford now offers specific self-management curricula for diabetes, arthritis, HIV, and chronic pain. Its Chronic Disease Self-Management Program is for people with any type of chronic illness or their caregivers. Stanford has developed an on-line version of this program, called Better Choices, Better Health, which NCOA is bringing to health plans and other payers.

The Stanford program has been translated into Arabic, French, Chinese, Vietnamese, Dutch, Norwegian, Somali, Italian, Bengali, German, Hindi, Korean, and Welsh. Several Stanford programs are available in Spanish versions that are geared to Hispanic culture. Nutritional information, for instance, is tailored to resonate with Latin Americans.

The chronic disease program is currently licensed by approximately 650 U.S. organizations.

Evidence of effectiveness

NCOA considers the Stanford program “the only self-care program in the marketplace that has data to demonstrate its effectiveness at reducing medical care utilization.”

In the oft-cited landmark study, published in The Permanente Journal (Spring 2002), six months after completing the program, 952 participants averaged 0.22 fewer hospitalizations and spent 0.8 fewer nights in a hospital than the control group. With a per-capita program cost of about $70 and 2002 hospital costs of $1,000 per day, the savings for each participant was approximately $750. After two years, participants reported 2.5 fewer annual visits to physicians.

Another major study, of 831 participants over age 40, found that two years after program completion, savings from fewer hospitalizations averaged $490 per person; fewer outpatient visits saved another $100 per participant. The Chronic Disease Self-Management program cost was $70 to $200 per person (Medical Care, 2001, Volume 3).

According to a study of 568 participants in England’s self-management program for people with long-term conditions, “The peer-led on-line programme conditions appears [cq]to decrease symptoms, improve health behaviours, self-efficacy, and satisfaction with the health-care system.”

Stanford’s own review of 13 U.S. or United Kingdom studies, each with 171 to 1,140 participants, cites the cost-effectiveness of chronic-disease self-management. Reviewers reported that for patients, the program “consistently results in greater energy, reduced fatigue, more exercise, fewer social role limitations, better psychological well-being, enhanced partnerships with physicians, greater self-efficacy, and is generally associated with a reduction in pain symptoms.” Remarkably, after program completion, participants “do not experience greater health care utilization when their disability worsens. The program is effective across chronic disease, socioeconomic, and education levels.”

As part of a research pilot program in 2008, Sanford (not Stanford) Health in Fargo N.D. used Stanford University’s questionnaire. Six months after completing the workshops, the 100 respondents reported measurable improvement in fatigue, shortness of breath, health distress, quality of life, and communication with physicians.

People who decide to try self-management usually “have several chronic conditions and are really struggling to get started on healthy changes,” says Rich Preussler, Sanford’s chronic disease self-management coordinator. “The strength of our Living Well program is its context for people to make small changes that they want to make, to gain confidence, and feel more control.”

Program participation

What characterizes self-management program participants? For on-line programs at Group Health Cooperative, a Seattle-based not-for-profit health care system, their median age is 54. Nearly two thirds are married. They average 15 years of education, and 83 percent are white. More than half have two or three chronic conditions; 11 percent have four or more. Their most common illnesses are arthritis (39 percent), hypertension (36 percent), diabetes (29 percent), and asthma (18 percent).

With self-management workshops, “one size doesn’t fit all,” says Greenberg. Some people won’t attend a group meeting, while others don’t use the Internet. “One facilitator, who has led both on-line and in-person groups, told me that by the third week, people are posting things they’d never share face-to-face.”

Anonymity is complete; even e-mail addresses are not posted. On-line programs, Greenberg expects, will appeal far more to men than will in-person workshops.

Group meetings

Around-the-clock availability is especially valuable to time-pressed full-time workers and caregivers, and to rural residents without access to distant in-person workshops. Severe weather also reduces attendance at in-person group meetings.

“Participants say the on-line program is especially helpful around holiday time,” notes David McCulloch, MD, FRCP, medical director for clinical improvement at Group Health. “They tell us the support of their peers helps them stick to their diet and exercise choices over the holidays.”

“A big challenge to health plans,” suspects Mike Thompson, a principal in the human resource services group at PricewaterhouseCoopers, “may be winning over the trust of members about programs like this, getting them to see self-management as a good part of their health. A huge upside is creating brand loyalty.”

To recruit participants, Sanford Health keeps its own doctors and nurses informed about “Living Well” programs. Its community partners, including churches and disease-specific groups, spread the word. So do local news releases about upcoming groups and announcements in Sanford Health newsletters. An average group has 10 to 15 participants, for a total of 3,500 since 1998. Sanford will launch the online version in 2011.

Through targeted communication and presentations, Group Health staffers encourage clinicians to refer patients to the program, and the program is available to community residents who are not members of Group Health. According to Group Health surveys, on-line participants learned of the program through:

  • Information posted on a Group Health Web site (47 percent)
  • Their doctor (11 percent)
  • Group Health’s employee wellness program (6 percent)
  • Targeted recruitment letters (19 percent)
  • Other sources (17 percent)

Each on-line group has about 25 participants. Nearly 300 Group Health members had enrolled by December 2010, with another 200 expected by June 2011. The on-line completion rate (participants logging in for four of the six sessions) is 74 percent. Group Health offers $2 incentives for taking 6-month and 12-month follow-up study surveys.

After six weeks, participants often want to maintain contact and continuing support. Some decide to form their own Google or Facebook group.

Thompson sees a growing national trend toward health care organizations finding more ways to serve people with chronic conditions. “Are disease management programs delivering value to the client?” asks Thompson, who looks carefully at ROI as well as effects on individual behavior. “For managed care providers, a big goal is bending the curve — decreasing the increases. If costs have been rising 8 to 10 percent, the hope is that they will rise only 5 to 7 percent, or less. Some companies have almost flattened the curve.” Others are beginning to ask how they can contain increases.

Group participants are more likely to ask questions and discuss medications with their doctors, observes Dan Kent, PharmD, clinical specialty coordinator at Group Health. “If they set realistic personal goals, they can sometimes reduce the dosage, or even come off medication. If they make changes to food choices — by reading [nutrition] labels and controlling portion size — and increase any [physical] activity, they can lower their blood pressure. When they’re at the point of diabetes, most patients, if they don’t already have hypertension or cardiovascular disease, are at very high risk.”


Kent appreciates the “self-driven, self-activated” aspect of the self-management program. “They come up with an idea about what to do and how much they think they can improve. For example, a patient with Type 2 diabetes who [follows all the recommendations] and loses weight can sometimes get off insulin. That’s a goal that an individual can choose. The self-management program’s support really broadens the perspective of what can happen, through taking baby steps.”

“This is a relatively inexpensive program for Group Health,” says McCulloch. “Patients who participate seem to be satisfied, and probably come in slightly less often, and are less likely to be hospitalized. It empowers people with chronic conditions.” He finds it very suitable for diabetic patients. “Anything you can do to empower [them] to feel better about themselves, understand their disease more, and see their doctor less often makes them more likely to take their meds and stabilize a bit.”

Big payoff

Greenberg at the NCOA concurs. “When diabetics’ blood sugar is so out of control that they face amputation or blindness, throwing a lot of treatment at them won’t change the trajectory very much. But giving them access before that point to self-management programs with proven efficacy offers a chance [to improve their condition]. That’s the big payoff.”

What’s involved in launching a Stanford Chronic Disease Self-Management program? Every organization offering an in-person Stanford program must purchase a license, good for three years. A yearly report about each program is required. For one program in one language, the basic fee is only $500. To offer more than one self-management program, fees begin at $1,000.

The Internet version, Better Choices, Better Health, is licensed exclusively through NCOA. Cost per participant ranges from $40 to $175, depending on the program’s scale and the health plan’s role in program delivery.

Having supervised Sanford Health’s Living Well program since 2006, Preussler says he has learned that it is necessary to have an infrastructure — “a coordinator, even part-time, and centralized registration system so [participants] don’t call the church or library, and so we can follow up. Someone has to handle logistics, supplies, and promotion, too.” Some community groups charge modest fees for meeting rooms.

Group Health, NCOA’s first partner in testing the on-line chronic disease program, received a two-year grant ($127,720) from the Group Health Community Foundation. Start-up took about nine months — considerably longer than anticipated. The main challenge: Developing a simple sign-in to the program through the Group Health member Web site. The study’s data collection involves substantial staff time. Group Health expects that once the pilot program concludes, far less staff time will be needed to administer these programs.

When NCOA surveyed health care organizations about why they offer chronic disease self-management, the most common answer was, “They deliver results.”

Greenberg says, “The primary cause of poor health behaviors among people with serious chronic conditions is not lack of knowledge. It’s depression and lack of confidence, often undiagnosed in this population. Sometimes the health system gives so much information that many people feel inadequate to the task and give up. Group support builds confidence and helps ease depression.”

Like Kent, Greenberg values the small, realistic action plans central to Stanford’s program. “A patient may say, ‘My grandson is coming to visit next week. I want to be able to walk around the block with him. So I need to walk 100 steps by Thursday.’” Posting a goal for the whole group to see brings accountability and encouragement.

A win-win

“It’s well understood,” Thompson observes, “that if people with chronic diseases take better care of themselves, they stay out of the hospital and costs go down. Becoming more involved in their health is good for patients and for the bottom line. It’s a win-win.”

McCulloch calls self-management “a wonderful resource for patients to get support from each other. It probably builds patient loyalty to Group Health. Given that it’s largely lay-led, it helps people feel less isolated as they learn from and problem-solve with each other. The fact that it can [also] be done on-line is just fantastic,” says Group Health’s medical director. “The patients love it, and so do we.”

Reach Carol Milano regarding this article at CMilano@ManagedCareMag.com.

Small increases in self-confidence are important, according to Rich Preussler, an administrator at Sanford Health in Fargo N.D.

It can be hard to win patients’ trust, says Mike Thompson, a PricewaterhouseCoopers principal.

Group participants are likely to be self-driven, says Dan Kent, PharmD, clinical specialty coordinator at Group Health.

“Patients seem to be satisfied, probably come in slightly less often, and are less likely to be hospitalized,” says David McCulloch, MD, a medical director at Group Health in Seattle.

Carol Milano

Chronic Fatigue Syndrome Poses Management Challenge

CFS is one of a number of diseases with an uncertain etiology and a substantial effect on patients but with few or no verified treatments

According to the Centers for Disease Control and Prevention, chronic fatigue syndrome affects between 1 and 4 million Americans. At least one fourth of these are unemployed or on disability because of CFS. Yet according to the CDC, only about half of those thought to suffer from CFS have consulted a physician for their condition.

Primary symptoms include unexplained fatigue for six months or more, in addition to any number of the following: cognitive dysfunction, postexertional malaise lasting more than 24 hours, unrefreshing sleep, joint pain without redness or swelling, persistent muscle pain, headaches of a new type or severity, tender lymph nodes, and sore throat. There are more than a dozen other less common symptoms.

Health plan medical directors find the situation vexing. “Like all managed care organizations, Independence Blue Cross struggles with establishing appropriate coverage policies and clinical programs to address conditions in which there is considerable clinical controversy,” says Donald Liss, MD, the plan’s senior medical director of clinical programs and policy. “Conditions such as chronic fatigue syndrome are particularly challenging because of the nonspecific nature of the diagnostic criteria, the lack of objective studies to confirm a diagnosis, and the wide spectrum of therapies prescribed.”

Clinical executives aren’t the only ones frustrated, says Robert McDonough, MD, the head of clinical policy research and development at Aetna. “Treating physicians are struggling to come up with cures,” says McDonough.

In addition, medical directors must consider the role medication should play. “Many of these people have concurrent psychiatric disorders such as anxiety and depression,” says McDonough. “It’s not that chronic fatigue syndrome is caused by depression or anxiety, but depression and anxiety frequency coexist, and treatment of these psychiatric problems will better enable the patient to cope with the chronic fatigue syndrome.”

CFS in the literature

It has been estimated that more than 800,000 adults suffer from CFS in the United States. The annual direct cost could be more than $8,000 per patient, with the total direct cost to society as high as $7 billion.

According to Charles W. Lapp, MD, at Hunter-Hopkins Center in Charlotte, N.C., most people who complained of the symptoms of CFS before it was officially defined in the late 1980s “were considered to be hypochondriacs or crazy, because there are so many symptoms and so many systems involved.” Lapp specializes in treating CFS.

What got people interested in it again were several outbreaks in the early 1980s, including one in Lake Tahoe that got a lot of attention. “It was written up in Rolling Stone magazine and labeled the ‘yuppie flu.’” This was right after AIDS was identified. “As a result, the CDC became very interested, wondering if it was ‘AIDS Minor.’”

McDonough says that, as of right now, CFS is a “diagnosis of exclusion,” meaning that it can be made only after other medical and psychiatric causes of chronic fatigue have been excluded.

“The CDC recommends performing a thorough history and physical and some basic laboratory tests to rule out other common causes of chronic fatigue,” he says. “These include a blood count with differential, an erythrocyte sedimentation rate, a chemistry screen, and a thyroid stimulating hormone level. Additional testing may be necessary based on the history and physical and basic laboratory tests. It is only after a negative workup for other common causes of chronic fatigue that you would come to the conclusion that someone has chronic fatigue syndrome.”

While there are no formal diagnostic methods, there are criteria that are based on subjective symptoms, according to Tanya Edwards, MD, medical director of the Center for Integrative Medicine at the Cleveland Clinic. The primary symptom is unexplained, persistent, or relapsing fatigue for at least six months. Then, four or more of eight additional symptoms must persist or recur during six or more consecutive months and not predate the disease. These are:

  • Impairment in short-term memory or concentration
  • Sore throat
  • Tender lymph nodes in the neck or armpits
  • Muscle pain
  • Joint pain without redness or swelling
  • Headaches of a new pattern or severity
  • Unrefreshing sleep
  • Post-exertional malaise lasting more than 24 hours

McDonough says that, “They usually have been very highly functioning individuals, and then something happens, sometimes an infection, and they’re suddenly wiped out. It’s like they’re struck down.”

According to Edwards, before making a CFS diagnosis, physicians should first check for an untreated low-grade infection, which can have similar symptoms. There is also significant overlap with fibromyalgia.

Health plan perspectives

At Capital District Physicians’ Health Plan (CDPHP), the thinking is that CFS, as defined in the scientific medical literature, is a real syndrome, and the plan does cover evidence-based care. “We treat this the way we would any other condition, in that we make sure the diagnosis has been appropriately made and that the proposed treatments fall within the scope of what the scientific literature supports,” explains Clifford R. Waldman, MD, senior medical director.

There have been some studies of medications specific to CFS. Currently, though, the plan pays for drugs that are designed to treat the symptoms, such as antidepressants, pain medications, and sleep medications. “One thing we realize is that because a drug is labeled an antidepressant doesn’t mean that it only treats depression,” he continues. “For example, antidepressants will alter sleep patterns. As a result, they have functionality in treating a number of different things, including a number of different chronic pain syndromes.” Thus, he notes, even though it isn’t fully understood how they work, there are some studies showing the effectiveness of antidepressants for CFS.

Scientifically-based treatments

Waldman says it is important to be sure that the people treating CFS be qualified and use scientifically-based treatments. “It is always important to identify instances of either the use of treatments that are not scientifically supported or overuse of treatments that are scientifically supported.”

In fact, he says, this is an area that can be subject to abuse. “One concern we have is that it is very easy for a provider to treat CFS with alternative treatments, without scientific evidence, and to end up with anecdotal evidence that they are working,” he states. “After that, they continue these treatments, claim expertise in the field, and encourage people to come to them, even though they don’t have any studies to show that what they are doing is effective.”

It’s crucial for clinical executives to follow an evidence-based approach, says McDonough. “We’re continuing to follow the medical literature on chronic fatigue syndrome. The hope is to better elucidate the cause of this condition, whether it is infectious, immunologic, neurologic, psychological, or of some other etiology. Knowledge of the cause of chronic fatigue syndrome will lead to more effective treatments.”

For Health New England, though, CFS coverage is a bit more sticky. Is CFS a legitimate diagnosis? “Sort of,” replies Thomas Ebert, MD, vice president and chief medical officer. “It is a legitimate condition from the perspective that it is a diagnosis, and that there are codes,” he explains. “It is also linked to fibromyalgia and certain chronic viral conditions.”

Unlike diseases that have very specific laboratory or clinical descriptors that can be used to make a diagnosis, it is more difficult with CFS, where there are fewer of these kinds of markers, Ebert says. “This is one reason these patients are difficult to treat, and it is difficult to affect the course of the illness,” he adds.

As a result, there has been a lot of epidemiologic work done on patients with CFS, who often have gone from doctor to doctor and had relatively high use of the health care system.

“Because of the chronic nature of CFS, this is usually not the kind of patient that does well seeing primary care physicians who are scheduled to see patients every 10 to 15 minutes,” Ebert explains. “As a result, these patients often end up going to specialists, and often lend themselves to receiving a team approach to care, including clinical medicine and behavioral health.” In some cases, though, Ebert says, the patients just learn to live with what they have.

So does Health New England consider CFS a legitimate diagnosis? “It is less important for us to consider it than it is for our network providers to consider it a legitimate diagnosis,” he replies. “It usually doesn’t rise to the level of a disease state where we dedicate a lot of resources, so there won’t be a disease management program, as there would be for people with chronic diseases.” However, he adds, some patients with CFS may end up using some of the health plan’s case management services intermittently.

In Ebert’s experience, some patients may also want to see physicians who are not in the health plan’s network. “My experience is that they don’t have any more success when they go outside the network than when they stay in the network.”

The condition is probably legitimate, he adds, but with caveats, because there are people who have many symptoms or complaints, not all fitting CFS. “However, let’s say that we have a cohort of people who meet these conditions for the long term. This subset seems to be real. These are people who have symptoms that clearly interfere with their lives, families, and work.”

These people do tend to use a fair amount of medical services for a while. “After that, though, they tend not to, because they don’t get cured, so they just try to learn to get along,” he continues. “This is what drives them to seek providers outside of the network, including alternative care providers.”

Coverage denied

In such cases, Health New England denies coverage, except in cases where a primary care physician or specialist in the network advocates sending the person outside the network. “If this is the case, we generally support it,” he states. “If the care they receive outside the network isn’t any more helpful than the care they got inside the network, they probably aren’t going to use much of that out-of-network care anyway.”

Managing Editor Frank Diamond contributed to this article.

A difficult disease

This article is the first of several that will look at medical conditions that have sparked controversy or debate — conditions that are “real” and, therefore, pose considerable challenges for health plans, plan sponsors, and clinicians alike. The first in this series is one that I have viewed with skepticism as a primary care practitioner, clinical educator, and former health plan medical director. Chronic fatigue syndrome frustrates health care practitioners, insurers, and the patients that manifest the constellation of symptoms that define CFS. Is CFS fundamentally behaviorally based? Is there some post-infectious immune related etiology — even in the absence of any indicators of chronic inflammation? Is there a genetic basis for CFS or perhaps a vitamin or trace element deficiency that underlies CFS?

To date, we have no compelling evidence for any underlying etiology. I remain a skeptic.

Steven Peskin, MD, MBA, FACP
Executive Vice President,
Chief Medical Officer
MediMedia USA

“I think there’s a general agreement that it is a true syndrome,” says Robert McDonough, MD, the head of clinical policy research and development at Aetna.

William Atkinson

Holistic Care Management Requires IT Integration

When we truly begin to manage the person and not the condition, there will be payoffs on both the cost and quality fronts

Managing the care of members with chronic disease — especially those with multiple conditions — is one of health care’s most confounding and costly challenges. As an industry, we have come up with many valid approaches — case management, disease management, utilization management, nurse triage, and health coaching/wellness initiatives. But in nearly every health plan, these initiatives are kept in their own silos, rather than put to use in a collaborative way that meets the needs of members.

The result is that care management falls far short of its potential. We wind up with duplicate efforts and costs, low member and provider engagement, and missed opportunities for intervention. Care management — done right — can improve quality and reduce costs. We must approach care management in a more holistic fashion. And we now have the tools and the understanding to do so.

Care management involves assessing individual needs to create a coordinated plan of care that is consistent with agreed priorities. It is designed to bring optimal outcomes using cost-effective care. Historically, health plans invested in core solutions that addressed different points along the care continuum. Looking back now, we see how each was developed to address a need identified at that point in the evolution of managed care and how each solution was limited by the technology of the day. Programs and systems designed for a certain purpose did not interact with other systems. They were uncoordinated.

There has been value in this care management work, but today we have an array of siloed programs that are misaligned, often duplicative, and far less effective than if they worked in a coordinated fashion. Today we live in a care management world that has:

  • Multiple care management tools
  • Different, incomplete data streams
  • Programs run by a diverse set of care managers, providers, and outsourced vendors
  • Inefficient workflows/processes intended to share member data and coordinate outreach among these stakeholders
  • Programs that are not connected, even when they target the same member

Connecting across the continuum

It is clear that we need a more holistic approach to care management. By holistic, I mean addressing all aspects of a member’s care needs — not just the disease processes and acute episodes. We need to consider the psychosocial and financial problems that affect a person’s ability to manage his or her health. And we must use the same principles of care management along the full continuum of care. All of this calls for a clean break from our reactive and fragmented approach to delivering care, which has been costly and rife with missed opportunities to improve member health.

What we need — and is too often missing — is rapid access to data that can help the full range of stakeholders identify when patients are veering off a treatment path or need adjustments in their care plans. The data currently available are too often separate from important and relevant facts that could identify opportunities to improve member outcomes. The solution is to connect data sources, audiences, and initiatives across care management disciplines. An approach that brings data sources together will break down the existing silos and deliver greater value and better outcomes.

When I use the term holistic care management, I think about how care initiatives, from a member’s vantage point, should comprehensively address his range of needs. From the plan’s vantage point, I think of integrated care management, wherein tools integrate the varied data streams and present a complete view of the member.

Triple-A approach

To optimize health, all stakeholders must work in partnership across the care continuum, with a system capable of supporting shared objectives. It is helpful to think of a “three As” approach:

Align the key stakeholders: Create transparency and coordination of information among all relevant providers, the patient, and the plan. Develop a structure of aligned incentives among providers, patients, and plans. Clearly define shared goals based on common and accessible information.

Automate the processes: Your workflow software should integrate utilization, disease, and case management. At the core, messages should create workflow. Send data, such as notice of an unfilled prescription or a worrisome lab result, to all relevant parties, and create an opportunity to keep the patient on a stable medical course. This allows health professionals and care managers to spend their time caring for and engaging with patients rather than scurrying around to collect and organize data. Automation that sends relevant messages to the right stakeholders creates the information transparency that supports aligned action toward common goals.

Activate the member: Bring the patient into active involvement. First create a care plan that truly addresses the whole individual and that provides patients and their support systems with the necessary information and resources to be active, engaged, and compliant with the plan of care. Multimodal communication tools are needed to reach members when and where they are ready to be engaged.

I envision the ideal care management system as a wheel. The hub is the workflow engine — a rules-driven workflow system. Information flows into the hub from many sources, which are the spokes, and back out to the various constituencies. The many spokes include:

  • Clinical decision support tool
  • Automated authorization and coverage determination tool
  • Personal health record
  • Member biometric data from home monitoring
  • Multimodal communication channels to and from members, providers, and plan
  • Health/wellness support mechanisms
  • Electronic medical record
  • Utilization management
  • Disease management tool
  • Population assessment tool
  • Analytics
  • Predictive modeling for gaps in care

Most organizations can leverage existing elements by integrating them with one another. Creating paths along which data may flow can lead to additional automation and workflow process improvements to reduce administrative costs.

All stakeholders benefit. Providers have greater access to real-time authorizations and point-of-care pre-authorizations and can view status updates on individual patients without contacting their plans. Payers can more readily assess populations overall to target high-risk patients for enrollment programs. Payers also can view data to assess provider performance and can then modify contracting and payment terms. The member benefits when the plan becomes an information broker. The plan can use the data to make timely adjustments to care plans and can execute new tasks through coordinated outreach. The payer also can play a role helping providers deliver more appropriate care to members, which has medical benefits for members and economic benefits for providers.

The challenge of Edna Jones

Let’s look at what holistic care management would mean for Edna Jones, 68, who represents the 10 percent of patients in the United States who account for 70 percent of all health expenditures. She has congestive heart failure and a history of diabetes and high blood pressure. In this scenario, Edna arrives at the emergency room with shortness of breath or weakness and is treated for decompensated heart failure. Medications are given to reduce fluid volume and improve oxygenation. Edna’s nurse reviews her medications with her and then sends Edna home. Perhaps Edna’s primary care physician is notified a few days later about the episode. Without any other action to alter the course of events, the likelihood of a similar episode in a few weeks is very high. A seemingly insignificant action, such as eating some potato chips before bed, may be enough to get Edna back in the emergency room.

Holistic care management might prevent the ER visit in the first place. With a good system in place, a care manager would routinely view the pharmacy data to know whether Edna was filling her prescriptions, and the data from home monitoring devices that would show whether blood pressure or weight was creeping up. Authorization or notification data would show Edna’s care encounters in real time. Anything amiss, including a high-cost profile, could trigger immediate outreach to Edna, to ask her how she was doing and to initiate action — nutrition counseling, perhaps, or education about medication use. This approach could prevent Edna’s deterioration in health and the utilization of costly medical resources, like the ER.

If Edna needs a knee replacement, the situation becomes more complex and the risks increase. With holistic care management, the care manager would be aware of the authorization request or notification, which would trigger a workflow to ensure that discharge planning takes into account Edna’s medical needs, as well as post-surgical ones. Does she have transportation to pick up her meds? Should a nurse check on herw An integrated system makes it possible to put these pieces in place to head off problems even before the surgical claim streams in.

At my organization, we have learned that such integration of information can reduce administrative costs significantly. For example, automation can reduce authorization-related administrative costs by 50 to 70 percent. Care coordination workflow software reduces the need for staff to enter double documentation in multiple systems or data collection tools such as Excel and Access. We see decreased staff time spent creating case and disease management plans and generating letters. And, it vastly reduces staff time spent on the 60 to 80 percent of pre-authorizations that could be automatically approved in real time. Care managers are more efficient when automatic notifications and online authorizations replace phone calls and faxes. The frustration level also drops for all involved. Also, staff members are freed up to practice “exception-based” utilization management, applying their expertise to only requests that require personal review and intervention.

On the path

Integrating clinical decision tools into the workflow also reduces inappropriate medical expenditure. Centralization of information reduces duplication of testing and administration. Integration of data can target populations and individuals for disease management enrollment, and start those members on a path of improved health and diminished need for the most costly intervention.

The value of holistic care management lies in the linking of data, people, and processes. Every stakeholder who contributes data or receives insights from data can help to change the course of events to improve a member’s health. All can reach clarity very quickly on identifying opportunities to improve a member’s care and how to act on those opportunities. A care manager who can see a complete picture for each member without needing to access multiple applications will spend more time engaged with members rather than with the system. That care manager will be freed up to work with more members.

Ultimately, the best care management is propelled by effective and streamlined interactions that address the member holistically. It engages members in their own care. Plans that do not activate members can only do so much on the member’s behalf. It is the engaged, activated member who can then help to manage his or her care, as well as the associated medical costs.

Emad Rizk, MD, is president of McKesson Health Solutions.

The best care management is propelled by effective and streamlined interactions that address the member holistically, says author Emad Rizk, MD. Without that, plans can only do so much.

The value of holistic care management lies in linking the data, people, and processes that can improve a member’s health.

Emad Rizk, MD
Medication Management

Antidepressants Work Best For the Severely Depressed

Studies suggest that the benefits of the medications for mild-to-moderate patients are minimal or nonexistent

Most health plans and pharmacy benefit management companies pay for antidepressants, and many maintain depression management programs, so they have a vested financial interest in the efficacy of treating depression through medication and disease management. At least 27 million Americans take antidepressants and more than 164 million prescriptions for antidepressants were written in 2008, totaling nearly $10 billion in United States sales and $20 billion globally, according to IMS Health.

JAMA article

The therapeutic value of antidepressants has been controversial lately — a recent article in the Journal of the American Medical Association, followed by a Newsweek cover story, questioned their effectiveness. But two studies published in the February 2010 Journal of Occupational and Environmental Medicine point to the absentee and productivity cost of depression — especially when it is untreated — and conclude that antidepressants and health plan-assisted depression management might reduce that cost.

“We believe in the value of testing for depression at the primary care level because of co-morbidities and the overall negative effect on patients’ lives,” says Edmund Pezalla, MD, chief clinical officer at Aetna Pharmacy Management, “and we aggressively recommend follow-up through our contact with physicians.”

The JAMA study, “Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-analysis,” was published in the Jan. 6, 2010 issue. It examined random placebo-controlled trials of antidepressants approved by the Food and Drug Administration for the treatment of major and minor depressive disorders.

The authors, led by researchers in the psychology department at the University of Pennsylvania, concluded that “the magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.”

The Newsweek story, published February 8 and titled “The Depressing News About Antidepressants,” pointed out that the January JAMA study was one of several, beginning more than a decade ago, that questioned the value of antidepressants. The story states: “As more and more scientists who study depression and the drugs that treat it are concluding, [the JAMA study] suggests that antidepressants are basically expensive Tic Tacs.”

Unsurprisingly, the JAMA article and especially the Newsweek story created something of an uproar. In its March 2, 2010, issue Scientific American said the two stories had created a controversy among psychiatrists — but added that at least four other meta-analyses published in the last eight years supported the recent JAMA findings.

“The essential facts about antidepressant efficacy are not in dispute,” states Scientific American. “In double-blind, randomized controlled trials … antidepressants show a small but statistically significant advantage over placebos. The debate is over the interpretation of these findings.”

Employers react

What is undeniable is that depression has a clearly demonstrated adverse effect on employers. “The cost of depression in the workplace is highly significant,” says Ronald Kessler, PhD, a professor of health care policy at Harvard Medical School. In June 2003, Kessler and colleagues published a study of the financial effect of depression, “The Epidemiology of Major Depressive Disorder: Results From the National Comorbidity Survey Replication,” and concluded that the disease costs as much as $51.5 billion a year in absenteeism and presenteeism, which is when employees are at work but fail to perform adequately because of an untreated or undertreated medical condition.

Two recent studies

Kessler’s conclusion — that treated or untreated, depression has a serious negative effect on productivity — is supported by the two recent JOEM studies.

One JOEM study, titled “Assessing the Relationship Between Compliance With Antidepressant Therapy and Employer Costs Among Employees in the United States,” demonstrates that absentee costs are lower when patients comply with medication therapy. Its objective was to assess effects of antidepressant treatment compliance on health care and workplace costs, according to the authors.

“Using claims data, we looked at two groups of patients plus a control group,” says Howard G. Birnbaum, PhD, a principal in the Analysis Group, a financial and business consulting organization in Boston, and lead author of the study. “The first was employees taking antidepressants for any reason — antidepressants are sometimes prescribed for conditions other than depression, such as anxiety or a sleep disorder. The second group was patients with a depression claim.”

By using workplace survey data linked to two employers’ health care claims, employees with depression (488) or antidepressant (1,224) claims were categorized into noncompliant or compliant groups. Compliance was measured through “medication possession ratios,” or refill rates. Annualized costs were compared between compliance groups for the employees with antidepressant use (regardless of diagnosis) and the subset diagnosed with depression.

Absenteeism costs were lower for patients compliant with antidepressant use ($3,857 compared to $4,907), regardless of diagnosis, and among diagnosed depressed patients ($3,976 versus $5,899).

“In both cases, compliant patients cost less than noncompliant patients,” says Birnbaum. He and his colleagues concluded that “increased compliance with antidepressants is significantly associated with reduced absenteeism costs.”

The second JOEM study looks at productivity and depression, and concludes that depressed patients create productivity costs, and its authors say treatment should include depression management.

The study, titled “Productivity Losses Among Treated Depressed Patients Relative to Healthy Controls,” used claims data to examine annual short-term disability and absenteeism costs for patients with depression who were treated with antidepressants and for a matched control group without depression.

The study, led by researchers from the consulting group Thomson Reuters, analyzed insurance claims and employee health and productivity data for more than 22,000 patients diagnosed with depression and treated with antidepressants. Researchers compared this study group with a control group of patients without depression.

They found that employees treated for depression were roughly twice as likely as people in the control group to use short-term disability leave. For workers treated for severe depression, the short-term disability rate was three times higher.

Short term disability

Average annual short-term disability costs were $1,038 for treated depressed patients versus $325 for the control group. They were $1,685 for a subgroup of severely depressed treated patients versus $340 for their controls. The authors concluded that “even when depressed patients are treated with antidepressants, there are substantial productivity losses. Therapies that can better manage depression may provide opportunities for savings to employers.”

“Despite the acknowledged effectiveness of antidepressant therapy, productivity costs related to depression persist even after patients receive treatment,” says lead author Suellen Curkendall, PhD, director of outcomes research at Thomson Reuters. “This may be because patients often don’t respond to the first type of antidepressant that they are prescribed.

Contributing editor Martin Sipkoff can be reached at MSipkoff@ManagedCareMag.com.

Martin Sipkoff
Plan Watch

Put DM in Doctors’ Hands?

Disease management should be a function of primary care, some industry proponents argue. Did someone say patient-centered medical home?

Nothing bolsters the reputation of a consultant more than making a prediction that turns out to be true. Under the Medicare Modernization Act of 2003, the Centers for Medicare & Medicaid Services launched eight disease management pilot programs throughout the country. Ariel Linden, DrPH, MS, president of Linden Consulting Group and a widely published researcher of DM outcomes, published a white paper in the spring of 2008 that explained why those pilot programs would fail.

“And shortly thereafter — guess what? — Medicare pulled the plug on them,” says Linden.

In that peer-reviewed article, titled “Medicare Disease Management in Policy Context,” Linden touted an approach by which “the primary care physician leads a team of specialists, nurses, dieticians, pharmacists, and health educators to provide and coordinate care for the ill population.”

An intensive approach emanating from a physician’s office is the only way that DM will work, Linden argues. “I mean there is nothing here that adds up unless you have this entire infrastructure and you are firing on all of your spark plugs.

“You need to have the medical group; you need to have the hospital associated with it; you need to have this whole infrastructure built around it; you need the information technology that will allow health information to be transferred between all the providers and participants. (For more about DM, see our cover story.)

“There must also be someone manning the phones reaching out to patients. There should be a pharmacist available to explain medications. A behavioral change expert and social worker must be involved also.”

Jodi Aronson Prohofsky, PhD, senior vice president for health management operations at Cigna, sees value in the push to make DM a function of the provider. She notes that Cigna is participating in several medical home pilot programs, including multipayer programs in Colorado, Pennsylvania, and Vermont, and it has a Cigna-only program in New Hampshire. She says that the pilot programs have yet to generate enough information about how worthwhile it may be to rely more on primary care.

Individual preference

“We completely agree with the concept,” says Prohofsky. “But I don’t know that the whole of the system we live with today is ready. We truly believe it should be the individual’s preference. I should be able to engage in the health care system any way I prefer. One option may be through my practitioner.”

Harvard Pilgrim Health Care strives to maintain good ties with physicians, ties that help with something as complex as DM, says Judith Frampton, RN, MBA, the plan’s vice president for medical management.

“We try to understand what would be most helpful to them,” says Frampton. “Some of them want online registries; some want things faxed to their office. So we’ll send, for example, something like, ‘Here are your diabetics. I use diabetics as an example, but it is the same for any condition. Here are the people who are overdue for X, Y, and Z. If we’ve got that data wrong, just correct it. And please put a check-mark if there is somebody you really want us to call.’”

Disease management needs to have the entire primary care infrastructure built around it if it is to succeed, says consultant Ariel Linden, DrPH, MS.

Frank Diamond
Cover Story

DM Grows, Though Under Fire

Some question disease management’s cost-effectiveness, but major insurers have seen enough to induce them to expand programs

We’ve grown accustomed in the last year and half to seeing seemingly invincible corporations and even entire industries suddenly find themselves wishing that the government would slap a “too big to fail” label on them. Most companies, however, still swim or sink in Darwinian waters where only the fittest survive.

There is no doubt that the approximately $2.5 billion disease management industry shoots the rapids these days. Skeptics are everywhere, even though some of the best health plans in the country tout their success at managing diabetes, congestive heart failure (CHF), coronary artery disease (CAD), and chronic obstructive pulmonary disease (COPD) and are branching into other areas. (There is serious debate about how cost-effectively asthma can be managed. See “Value of Asthma DM Disputed,” below.)

Value of asthma DM disputed

Harvard Pilgrim Health Care, Aetna, and Cigna are three major insurers that have robust asthma DM programs that they have no intention of jettisoning. Yet voices in the DM industry question whether a DM asthma program can ever truly control costs.

“Trying to implement asthma for the few-and far-between asthmatics that might be out of control is ridiculous,” says Ariel Linden, DrPH, MS, president of Linden Consulting Group and a widely published researcher of DM outcomes.

The asthma patients who wind up costing the system the most are those who never have an asthma attack and never take their medications as a result. Then, suddenly and seemingly out of the blue, they have an attack.

“They don’t have any medications on them,” says Linden. “They end up in the ER because they can’t breathe. The hospital admits them and keeps them there overnight, gets them well-medicated and sends them back into the wilderness, Meanwhile, it just cost the health plan $7,000. Is that the kind of model that makes sense?”

Different view

Al Lewis, JD, president of the Disease Management Purchasing Consortium, agrees that asthma is tough to manage, though he doesn’t agree with Linden’s reasoning.

“It is kind of the opposite,” says Lewis. “If you have 100 mild asthmatics, like my son, in any given year maybe three of them will end up in the ER for between $1,500 to $2,000. To put 100 people on controller meds would cost $600 or $700 apiece per person for a year. So, you don’t want to be overcontrolling. You don’t want to be pushing people to get controller meds that they don’t really need. Maybe they really are mild asthmatics.”

Lewis is lately warning health plans and vendors about taking on asthma: “Do very little asthma on a patient-by-patient basis because it turns out that asthma costs more to control than it is worth, at the margin.”

Harvard Pilgrim’s success has to do with managing asthma through providers, he adds.

“It costs more to control mild asthma than it does to take the small chance that they might end up in the ER. Do diabetes, heart failure, COPD, and CAD, in some cases, if the health plan is doing a good enough job, but emphatically not asthma.”

A direct hit in a February 4 Business Week article titled “Take Your Meds, Exercise — and Spend Billions” asserted that the cost-cutting advantages of DM have been, to put it tactfully, overstated. Then there was the little matter of the eight Medicare DM pilot programs that were supposed to measure how much money can be saved. They were launched under the Medicare Modernization Act of 2003, but last year the Centers for Medicare & Medicaid Services pulled the plug on them because the agency failed to see any positive results.

Medicare pilot programs

Ariel Linden, DrPH, MS, president of Linden Consulting Group and a widely published researcher of DM outcomes, recalls: “Medicare said, ‘All right, we don’t know if it works or not; the literature doesn’t say you work. We’ll create these randomized control trials. We’ll give you 20,000 patients. And we’ll have 10,000 controls. We’ll let you guys run with it.’ And guess what? None of them were effective. Some of them dropped out early when they saw they weren’t working. The rest just fell flat on their faces.”

Al Lewis, JD, president of the Disease Management Purchasing Consortium, who for the most part represents the employer purchasers of DM, not the providers, agrees that DM faces a perception problem. “It’s not enough that GM makes good cars now,” Lewis observes. “For a quarter of a century they made lousy cars. So you can’t just say, oh our cars are good, and expect people to start buying them.”

Gordon K. Norman, MD, is the chairman of the board of DMAA: The Care Continuum Alliance, formerly the Disease Management Association of America. He says that there may have been too much emphasis in the past on the industry’s cost-saving value as opposed to how it improves outcomes.

“I mean no one goes to a doctor to save money,” says Norman. “No one goes to a hospital to save money. Health plans don’t invest in the things they pay for to save money. But when it comes to health management services or DM, suddenly the amount of health improvement seems to go out the window and the amount of savings becomes the only thing focused on.”

To underscore how difficult things have become, it need only be noted that Linden, Lewis, and Norman are three of DM’s biggest boosters.

Still, don’t start looking for obituaries of DM providers. Patients with chronic disease account for 75 percent of overall health spending, according to the Centers for Disease Control and Prevention, and 99 percent of Medicare spending, according to Johns Hopkins University. Many plans still consider DM one of the best methods for taking on those daunting numbers, certainly in terms of the clinical processes it employs. But does it save money?

Norman offers a clue. “The fact is that it is a two-and-a-half billion dollar industry of outsourced health management programs and I don’t think that would be the case with all the steely-eyed, green-shaded CFOs and actuaries of corporate America looking on.”

Cost avoidance

There are two reasons to want DM programs for CHF, CAD, diabetes, and COPD, Lewis says. First, the cost-avoidance benefit is great, compared to how much it costs to control the condition. Second, these conditions, by and large, are not well-controlled outside of DM programs.

“Generally speaking, for disease management to work, there have to be many avoidable admissions — admissions that are avoidable by better outpatient management, where you don’t throw money at the outpatient management, ” says Lewis. “That can happen with these four and with some of the suite of rare diseases.”

Those four diseases are the ones that are “with the patient for a longer period,” says Burton I. Orland, RPh, a consultant and member of MANAGED CARE’s Editorial Advisory Board. Managing them won’t be “an overnight success, so the HMO sees improvements over a longer period. Patients tend to stay with their MCO because of a successful DM program, so there is a value to having the MCO’s nurse case managers also follow up with the patients.”

So if DM successfully manages those four, can that success be replicated with other diseases?

A study in the December 2007 issue of the American Journal of Managed Care (see “For Further Reading,”) suggests that many in the DM industry believe that it can. The study says that “although disease management programs have traditionally focused on more severely ill patients with common chronic conditions such as diabetes mellitus … and congestive heart failure (CHF), more recently the scope of disease management has expanded to include programs aimed at all patients with a condition regardless of severity (commonly referred to as population-based disease management) and at patients with rare and costly conditions (e.g., hemophilia and autoimmune disorders).”

Judith Frampton, RN, MBA, vice president for medical management at Harvard Pilgrim Health Care, says that in some ways, DM is a victim of its own success. “Why is it that diabetes disease management programs or cardiac disease management programs aren’t creating the return on investment yield that they once did? The reason is that doctors who weren’t practicing evidence-based medicine and patients who didn’t understand self-management skills 15 years ago are practicing them now.

“Other factors have also contributed,” she says. “One example is that the kinds of drugs people have today that can help them lead active and healthy lives even though they have congestive heart failure just weren’t available 10 or 15 years ago. Pharmaceuticals and other kinds of procedures and technology have changed the face of the old DM, but the model of somebody taking the time to talk to people about what they may not know, and what they may not know about how to avoid complications, is really the approach.”

Diabetes numbers

Lewis agrees with Frampton’s assertion about DM being a victim of its own success in regions where people have good access to medical care, where the health plans are conscientious, and where there is a culture of health, as in eastern Massachusetts.

“There have been reductions in events for CAD because of better-than-usual care and prevention,” says Lewis. For the other conditions, the technology is improving, but more people are being diagnosed with some of these conditions. “Diabetes, for instance. What is actually pretty impressive is that the prevalence of diabetes is actually way up in the last 10 years, but the incidence rate for people going to the hospital for diabetes is actually about flat. So technology is making an impact.”

Lewis adds that good DM involves more than just making “a ton of outbound calls,” a phrase that draws a reaction from Linden akin to how a lion responds to a rare steak being waved before its eyes.

“We Americans love simple fixes, but this isn’t a simple thing,” says Linden. “The truth of the matter is that these patients are usually very complex cases and they have got five different chronic illnesses.”

Harvard Pilgrim’s Frampton disagrees, saying that “one outbound call is not the same as another. Our nurses are clinical specialists in the area that they are working in. They are not generalist nurses, though most of them are adequately trained [for that]. But to get the nuances of the drugs, to understand the specificity of the condition, you need a specialist.”

Further, Harvard Pilgrim’s nurses do motivational interviewing. “Our outbound callers are trained in behavioral change techniques, and that makes a difference. We measure whether or not the interaction has resulted in a care plan. The care plan has to have goals that the nurse would perceive as goals, but it also has to have goals that the patient would see as goals. All of that makes it a more effective interaction.”

By way of anecdotal evidence, Frampton has hundreds of e-mails, letters, and phone calls from satisfied members. “All health care is local,” says Frampton. “Our nurses are from the area. They know Dr. Smith; they know the drugstore on the corner. Some of the call centers from some of the disease management programs are nowhere near the people that they are calling. I’m not saying it is impossible to do it from a call center, but our nurses have accents like they are from Boston or they are from Maine. It makes a difference.”

Prochaska change model

Marla Tobin, MD, medical director for Aetna’s Mid-America Region, says that Aetna’s nurse callers use the Prochaska change model in trying to determine when someone is ready to adopt a healthy lifestyle. “Our nurses are taught the Ask-Me-3 technique — What three questions should I ask my doctor today when I go in to visit? So the patient has a pertinent agenda that he goes to his doctor with. He understands his medication and diagnosis. He understands what he must do next and to take charge of his life.

“There are disease-specific things that we want people to understand as well,” adds Tobin. “We want a person with congestive heart failure to weigh himself, to understand the importance of salt in his diet, to know how to get a blood pressure reading, either taking his own or having a nurse do it. We want the coronary artery disease patient to understand what the symptoms of heart disease are.”

This saves money, according to Aetna’s in-house ROI studies. A 2008 study compares members in the Aetna Health Connections disease management program with members with similar conditions who were not enrolled in the program. Company officials say that patients in the Health Connections program had 26 percent fewer inpatient admissions for diabetes, coronary artery disease, congestive heart failure, and stroke. Overall, the medical costs were 10 percent lower — $5,452 vs. $6,040 per patient per year.

Some of this comes down to helping patients follow their prescribed pharmacy treatment. Sure, more people taking more medications can actually cost the members, the employers, and the health plan money up front, but it winds up reducing hospital admissions in the long run, says Tobin.

She calls DM programs for diabetes, asthma, CAD, CHF, and COPD the anchors of the industry. “If you want to talk volume of patients, you talk about those,” says Tobin.

There are other conditions and diseases that are ripe for the sort of intense member assistance that DM provides. In fact, the plan manages 36 diseases through Health Connections. (See “Aetna Goes Whole-Hog for DM,” below.)

Aetna goes whole-hog for DM

Aetna’s Health Connections disease management program is distinguished from traditional DM approaches in that it focuses on the whole member profile, including all clinical conditions and comorbidities, say company officials. It also focuses on those problems that are shown to be susceptible to targeted interventions. Eligible members are engaged (or receive an invitation for engagement) based on their gaps in care and clinical concerns as expressed in an opportunity score determined by their clinical and claim history.

Aetna officials say that this approach allows the company to better support patients suffering from a host of chronic diseases. It also means Aetna Health Connections can apply DM processes to diseases and conditions that have not historically been considered candidates for such an approach, such as migraine and rheumatoid arthritis.

  • Vascular
  • Heart failure
  • Diabetes — adult & pediatric
  • Coronary artery disease
  • Peripheral artery disease
  • Hypertension — adult & pediatric
  • Cerebrovascular disease/stroke
  • Hyperlipidemia
  • Pulmonary
  • Asthma — adult & pediatric
  • Chronic obstructive pulmonary disease (COPD)
  • Orthopedic/rheumatologic
  • Osteopenia
  • Osteoporosis
  • Osteoarthritis
  • Rheumatoid arthritis
  • Chronic lower back pain
  • Gastrointestinal
  • Gastroesophageal reflux disease
  • Peptic ulcer disease
  • Inflammatory bowel disease (Crohn’s disease)
  • Chronic hepatitis
  • Neuro-geriatric
  • Geriatrics
  • Migraines
  • Seizures
  • Parkinsonism
  • Cancer
  • General cancer
  • Breast cancer
  • Lung cancer
  • Lymphoma/leukemia
  • Prostate cancer
  • Colorectal cancer
  • Renal
  • Chronic kidney disease
  • End stage renal failure
  • Other
  • Weight management — adult & pediatric
  • Cystic Fibrosis — adult & pediatric
  • HIV
  • Hypercoagulable state
  • Sickle cell disease — adult & pediatric

“Depression is huge if you look at the cost of treatment and the number of comorbid situations,” says Tobin. “We integrate our behavioral health with our medical just for that reason. The data support that 70 percent of heart attack patients have depression before, after, or during the time of their heart attack. There are high incidences of depression for people who are off work for a long time with a disability like back pain.”

Aetna’s DM effort is not only incorporating more diseases, it is also expanding demographically. “We have DM for both adults and children,” says Tobin, “because asthma, weight management, and sickle cell are the kinds of diseases that can affect kids and really change their lives.” While debate continues about DM’s effectiveness, the commonsense connections it makes have long been evident. “If you don’t deal with the depression as well as the back pain, you are not going to get the person back to work,” Tobin continues. “We manage to where the patient is today.”

Let’s say that somebody is more concerned with getting to her daughter’s wedding in May than in talking about diabetes today. “We talk to her about things she can do to be healthier between now and May,” says Tobin. “That may be a healthier lifestyle and may be controlling her lung disease or kidney disease or some other disease. As we win her confidence and get her toward that goal, then she is willing to let us help improve her diabetes.”


Doing DM in-house allows Aetna to coordinate medical and pharmaceutical treatments more easily. For instance, patients with rheumatoid arthritis — another condition that has become a recent candidate for DM — might use injected anti-TNF agents.

“For appropriate use of such specialty pharmacy drugs, we want the member to really understand the right way to use the medication and how to control the disease,” says Tobin. “Those agents cost a lot of money and you want to use them wisely to make sure that the patient is doing the right thing for his rheumatoid arthritis to get the most benefit from the expensive drugs you are using.

“Same thing with some of the cancer treatments. Same thing with some of the kidney diseases. You want to make sure that lifestyle, exercise, other medical conditions, and drug use programs are dovetailed and the information is exchanged between them.”

Time is the ingredient that will decide whether diseases and conditions not traditionally managed by DM could be managed, says Jodi Aronson Prohofsky, PhD, senior vice president for health management operations at Cigna.

“You want to impact people while they are still healthy — before they become ill, especially chronically ill,” says Prohofsky, citing the work undertaken by Dee W. Edington, PhD, the director of the University of Michigan Health Management Research Center. “We know that the rewards that employers will see might be five to ten years out.”

Cigna has been working on a depression DM program for about four years.

“We’re not just asking people whether they are depressed while we’re working with them on other diseases,” says Prohofsky. “We already know that depression is comorbid with a whole host of other diseases. We are combing our data, utilizing our analytics to identify people who are depressed who may have bipolar disorder, who may have an anxiety disorder, and we are proactively reaching out to them to engage them in a full-fledged DM program.”

Traditional DM puts a lot of stock in behavioral change. The same approach should apply to depression — things like medication or other treatment plan compliance, for instance.

“Or planning for the relapse, for the time when you are not going to be as healthy,” says Prohofsky.

Not just the bottom line

Talking to Prohofsky about depression DM creates the impression that she could be talking about any DM program, which is the point, she says.

“There are conditions that you want to give priority because we know there is potentially a good return on investment, such as heart disease and COPD. But there is an expanding list of diagnoses we should be looking at, such as weight complications, because of morbid obesity, depression, and a whole host of other diseases.”

Those might be conditions that Cigna reaches out to beneficiaries about because patients may not know that they have them. “Maybe they don’t realize the risks associated with it. Maybe they have a track record of just not managing it very well. What if we just said, if you need any help with any illness whatsoever or, frankly, just to retain your health, what if you were free to call in to us and we will provide you the same resources to help you manage your health? That’s where we are today.

“Things like migraine headache, chronic stress, musculoskeletal pain, or other chronic pain syndromes,” Prohofsky continues. “Depression belongs in that category as well. Those are conditions that arguably are driving higher indirect health costs for many employers because of their prevalence more than the rare individual with heart failure who might be in that employer’s workforce. But for many employers, even non-Fortune 500 employers, some of these more prevalent, less severe conditions are nonetheless robbing them of productivity in a way that they are finding it cost-effective to invest in programs that help with these conditions.”

Lewis says that as DM begins to take on rare diseases, it is not so much a question of making people change their behavior as it is a question of making sure people have all the information.

“At this point if you are a health plan and you can’t answer a simple question like What is my heart attack rate per thousand today and what was it like five years ago, then you are not doing your job,” says Lewis. “All the valid methodology is based on measuring events.”

Tobin agrees. “I’ve worked for three managed care companies and there have been considerable differences between their programs,” she says. “The differences that you see in the literature may be the fact that you’ve got apples and oranges comparisons of what works and what doesn’t work. If it is done correctly in a well-run program integrated into your health plan, it does work well.”

Managing Editor Frank Diamond can be reached at FDiamond@ManagedCareMag.com

Many focus on DM’s savings while concern for health improvement “seems to go out the window,” says Gordon K. Norman, MD, of DMAA: The Care Continuum Alliance.

Revenues (millions)

Management of rare diseases bright spot as DM industry’s growth slows

DM vendors continue to make money, but the rate of revenue growth has slowed in recent years, according to the study “Leading Disease Management Organizations: Fall 2009,” by Health Industry Research Companies.

“DM industry revenue growth appeared to flat-line in 2009, making last year the first time in five consecutive years that DMO revenues did not grow at a double-digit pace,” says Al Lewis, JD, president of the Disease Management Purchasing Consortium. The slowdown is attributed to the recession and to lower growth rates in DM programs managing cardiovascular and respiratory diseases. One positive: “Many of the nontraditional disease states for DM, including cancer, rare diseases, and maternity, experienced strong revenue growth.”

Growth in DMO revenue by disease state

Source: Health Industry Research Companies, Summer 2009.

Plans said to do DM best are expanding programs
Health plan Major diseases or conditions historically managed DM categories created in 2009
Blue Cross of Alabama Common chronic, wellness, pain Oncology
Blue Cross of Delaware Common chronic Wellness
Blue Cross Blue Shield of Florida Common chronic, rare diseases None reported
Blue Cross Blue Shield of Massachusetts Common chronic, ESRD, rare diseases, asthma Wellness, oncology
Blue Cross of Nebraska Common chronic, wellness None reported
Blue Cross Blue Shield of Rhode Island Common chronic, health and wellness Low back pain
Blue Cross of Vermont Common chronic, plus “At Risk Suite” including hyperlipidemia, obesity, metabolic syndrome Wellness
Boston Medical Center Health Net Plan Common chronic Depression
Capital District Physicians’ Health Plan Common chronic None reported
CareFirst Common chronic plus ESRD, wellness, health coaching, lifestyle management None reported
ConnectiCare Common chronic, high-risk maternity, ESRD, complex case management, transplant case management Wellness — HRA, health coaching outsourced to WebMD
Harvard Pilgrim Health Care Cardiac, common chronic, oncology, rare diseases High risk pregnancy
HealthPartners Common chronic, rare diseases, complex case management, cancer, high-risk maternity, low back pain Low back pain
EmblemHealth Common chronic, ESRD, complex case management, high-risk maternity, rare diseases, pediatric diseases, NICU, HIV None reported
Providence Health Plan Common chronic, ESRD, cancer, inflammatory bowel disease, rare diseases, maternity, complex case management including transplant None
Summacare Diabetes, asthma, CHF None reported
Source: “Leading Disease Management Organizations: Fall 2009.” Eighth annual report. Health Industries Research Companies, 2009.

For further reading

“Medicare Disease Management in Policy Context,” Spring 2008. Health Care Financing Review. http://www.managedcaremag.com/s/9

“Chronic Diseases: The Power to Prevent, The Call to Control,” December 2009. Centers for Disease Control and Prevention. http://www.managedcaremag.com/s/a

“Chronic Conditions: Making the Case for Ongoing Care,” November 2007. Johns Hopkins University. http://www.managedcaremag.com/s/b

“Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?” December 2007. American Journal of Managed Care. http://www.managedcaremag.com/s/c

Cigna these days is branching out to manage things like migraine and chronic stress, says Jodi Aronson Prohofsky, PhD, the plan’s senior VP for health management operations.

“One outbound call is not the same as another,” says Judith Frampton, RN, MBA, of Harvard Pilgrim Health Care, whose nurse callers are clinical specialists.

Depression is huge because it is comorbid with other conditions, says Aetna’s Marla Tobin, MD. For instance, depression can accompany back pain.

Why Harvard Pilgrim believes in DM

Disease management has come under fire of late, including “Take Your Meds, Exercise — and Spend Billions” in the February 4 issue of Business Week, but there are dozens of health plans, including Harvard Pilgrim Health Care, that remain true believers.

“Without naming names, I definitely think that a vendor that makes a profit doing disease management has it in its interest to create a methodology that looks as good as possible,” says Judith Frampton, RN, MBA, vice president for medical management at Harvard Pilgrim Health Care. “I’m not saying it is dishonest. I’m just saying it is the methodology. You can make numbers do lots of things. We are not-for-profit so it doesn’t behoove us to trick ourselves.”

Harvard Pilgrim’s data show improvement in how the plan has managed some diseases.

“For instance, you can see a reduction in cardiovascular events,” says Frampton.

Number of inpatient and ER events per 1,000 Harvard Pilgrim members compared to the national average

Harvard Pilgrim

National average

Congestive heart failure

Coronary artery disease

Pre DM

Diabetes program introduced

Partial DM

Cardiac program introduced

Full DM

Diabetes & cardiac full implementation



Source: Disease Management Purchasing Consortium database presented to the World Health Care Congress, April 15, 2009

Frank Diamond
Managing Editor

Health Management Uses IT To Reduce Future Costs

Payers must manage the care of all members, regardless of how sick or well, to control escalating treatment expenditures

Hard hit by the recession, employers of all sizes are reassessing the value they are getting from their health plans. Their conclusion? It is not enough. Employers want more — greater value, better information, and more help managing employee medical costs and utilization. Employers increasingly recognize that it is better to manage the health of their workforce than to manage the cost of illness, and they want their health plans to contribute.

Insurers, then, need to play a larger role in managing member care and costs if they want to survive. There is only so much they can do on the back end of a claim or through network discounts. To add value and meet employers’ needs, insurers are transforming their business models to give themselves greater influence, up front, on their members’ health. One way is to focus on prevention through health and wellness programs.

Employers want payers to play a more active role in promoting the health of their employees and effectively managing disease, especially as obesity — the forerunner of pricey chronic conditions like diabetes and heart failure — approaches epidemic proportions and occurs earlier and earlier in life. Chronic disease has a real effect on employers’ bottom lines, affecting productivity through lost time and disability. Wellness and preventive care coupled with incentives are now being considered or offered by many large employers, representing a huge growth potential for payers who want to take advantage of the market.

Medical management is evolving beyond traditional utilization metrics and beyond case and disease management. It now encompasses the broader capabilities of health management, which is designed to capture and attend to the needs of all members regardless of where they fall on the continuum of care, from the worried well to those who require end-of-life support.

Continuum of care

Incorporating health management into the payer business model is crucial, but health care plans must be strategic about how they set up such programs. This is not a case of “one product fits all.” Insurers that invest heavily in health management programs that do not control employers’ medical expenses will find themselves at a competitive disadvantage.

Health management

Potential dividends for payers that offer health management programs include the early identification of patient risk factors for chronic disease, early intervention, better patient outcomes, market differentiation, and cost control.

Some would argue that the information insurers have about their members is more comprehensive than the information that physicians have about their patients.

The ability to identify high-risk patients is valuable. Insurers have access to a wealth of information — claims, personal health records, health risk assessments — that could provide great insight into members’ health status. In fact, some would argue that the information insurers have about their members is more comprehensive than the information that physicians have about their patients. But that information is not being used to its fullest potential.

If payers aggregate the patient clinical data siloed in their many and sometimes incompatible information technology (IT) systems and analyze it to identify trends and best practices, that information can be extremely valuable not only to clinicians, but also to health managers. If they do a better job of utilizing the information they already have and rethink their role in health management, payers can become active — rather than reactive — in managing care and costs. For example, once patients are suffering from diabetes, payers must field many claims from multiple physicians — from podiatrists to dentists — serving the same patient. Reactively managing these health care costs is much less cost-effective than proactively reaching out to patients whose body mass indexes indicate the danger of developing diabetes.

But shouldn’t physicians have access to this comprehensive patient information? Why are payers being thrust into the role of health care manager? Constrained by high overhead expenses, limited staff, and outdated IT systems, physicians are frequently unable to collect and store data, and they may be reluctant to share clinical information on their patients with insurance companies. Payers can play a potentially valuable role as physician extenders by providing doctors with more complete patient histories that can be discerned in claims. While this is not happening yet and although payers cannot give physicians direct access to their claims, the comprehensive picture that payers can paint of individual patients’ health histories (through details on hospital visits, prescriptions filled, etc.) can be of great help to primary care physicians.

Do it yourself — or not

Many payers have long outsourced their medical management programs, which has proven lucrative to vendors. But just as employers are demanding more value from their health insurers, so are insurers demanding that their health management vendors demonstrably control members’ medical expenses. Because there is no solid methodology for quantifying the savings realized by preventing illnesses and complications, payers that contract with health management companies sometimes question the return on their investment, leading them to explore the feasibility of administering those programs themselves.

The decision to operate one’s own health management programs, outsource them, or do a combination of both — as is common with most insurers — is an individual one that must take into account the cost-effectiveness of each approach and a payer’s internal resources, especially its number of administrative and clinical support staff. The decision will be heavily influenced by how well health management organizations can differentiate their service offerings and demonstrate their ability to control costs.

Whether payers outsource or administer their own health management programs, they must be as cost-effective as possible. If administering their own programs, payers must use thoughtful and extensive planning. A payer must streamline processes and resources to reach aggressive cost-cutting goals.

Most payers employ an impressive cadre of customer service representatives who tend to members’ administrative questions, and they retain clinical staff to support their members’ health care needs. But if these employees are not used effectively or do not work together, a payer’s member services offerings can be undermined.

Rethinking how their staff interacts with members can help payers lower the cost of their health management services and maximize patient outreach. This could include eliminating positions that do not add value to health management programs, redeploying existing resources, redefining staffing ratios, giving tasks to appropriate staff, and developing and deploying an effective recruiting strategy.

Payers can enhance the value that both administrative and clinical employees bring to a company if they ensure that they work together to offer comprehensive health management. For example, administrative staff can reach out to new members by calling them, welcoming them to the plan, and asking if they have any questions about their benefits.

But if payers call members to discuss their specific clinical care needs, patients are often — and understandably — reluctant to do so. For example, after a payer pieces together a member’s claims and identifies a high risk of diabetes, a customer service representative may call that member to discuss preventive care. Members often will not take the call out of fear of being dropped by their insurers.

A better approach to customized health management would be to ask a nurse to call a member both before and after an office visit. Beforehand, the nurse can start building rapport with members, reminding them of the visit and asking them if they have transportation. After members’ visits, the same nurse can follow up with individual patients with a courtesy call, making sure they understand their treatment plans.

The call may go something like this: “I understand you just saw Dr. Smith. I am calling to ask if you understand your diagnosis. Have you filled your prescriptions? Have you made an appointment with the specialist to whom you were referred?” At this point, members will most likely be more receptive to the nurses’ self-care suggestions.

Several payers are already doing this. They are especially having success with calling patients after hospital visits to prevent re-admissions. During such calls, nurses help patients reconcile their before-hospital versus after-hospital medications. Often, patients’ prescriptions will change during a hospital visit, and those changes will not be explained to them, leading to confusion and possible complications.

This in effect transforms payers’ clinical employees role to back-office physician support. When payers give patients’ primary care physicians the results of specialist visits, the names of prescriptions filled, and hospital discharge instructions, they help physicians maximize the effectiveness of patient visits. This puts payers in a position to significantly cut the risk of disease escalation and hospital readmission while also improving physician relations.

Although in-house health management programs can be expensive, it is not difficult to determine what resources are needed to conduct them. A simple review can determine a company’s staffing and budgeting needs.

Insurers will ultimately pay more on the back end if they do not control their members’ illnesses.

For example, if an insurer decides that it wants to review its members’ hospital admissions, it must determine how many admits per 1,000 members it is averaging. That will tell the insurer how many reviews it must conduct. Then it must determine what resources it needs to do the reviews effectively. The insurer must ask itself: What is the ease of use and efficiency of my current programs? Do I need to add staff or IT resources?

Granted, hiring additional staff and investing in new IT systems can be pricey, but insurers will ultimately pay more on the back end if they do not control their members’ illnesses.

Rapidly evolving health care market trends and health care reform are causing insurers to rethink their roles, shifting from being reactive gatekeepers to being proactive and actively engaged with providers and members in health management. Whether a health plan operates its own health management program or outsources it, an effective program is becoming essential to the success of insurers’ existing business models.

Jackie Mazoway, RN, is a manager in PricewaterhouseCoopers’s health industries advisory practice.

WellPoint’s successful health management pilot program

Some insurers have already illustrated the effectiveness of innovative health management programs. In 2007 in Dayton, Ohio, WellPoint, the largest health benefits company in the United States, conducted a successful pilot program with 10,000 members.

Working with a health IT vendor, WellPoint conducted a community-based effort in collaboration with Kettering Medical Center. They sought to integrate administrative data from WellPoint systems and clinical data from Kettering with data from other clinical sources in the community to improve quality of care and to control expenses.

For the program, WellPoint used a health IT tool known as an individual health record (IHR), which allows electronic health records and personal health records (PHRs) to communicate. Patients see and contribute to their records as PHRs, while doctors use them as EHRs. The IHR also supports electronic prescribing and enables exchange of data within a region. In addition, a real-time rules engine generates evidence-based medicine alerts, benefit optimization recommendations, and pay-for-performance metrics.

WellPoint and Kettering developed a process to ensure that the data were meaningful, accurate, and useful, capturing information from multiple clinical and non-clinical sources. For example, data for one mammogram can be found in many different sources. It is recorded in the scheduling system and in the EHR, as well as in the radiology system that performed the study and as a claim that was paid by the insurance system.

The IHR system receives or pulls data from each step along the way and rationalizes it into a single representation of what happened, and it does this in real time. This allows knowledge to be obtained as to exactly where patients are in the management of their disease or prevention. If a patient schedules an appointment but misses it, a reminder can be sent. If a physician orders a mammogram, but the patient does not schedule an appointment or does not show up for an appointment, the physician and the patient are alerted. This allows comprehensive management of the care process in greater detail than is possible in traditional paper-based care settings.

The pilot program also incorporated patient-generated notes, patient-oriented wellness programs, and prevention reminders. For example, a patient with diabetes would receive an electronic note in the system reminding him or her when it was time to get a lab test for blood sugar levels. Both the patient and the doctor would have access to the same full medical information and physician treatment plans.

According to a study conducted by HealthCore, WellPoint’s outcomes research subsidiary, members using the system during a one-year period reduced health care costs in their medical benefits by 7.4 percent more than non-users. Users were also 10 to 38 percent more likely to receive key disease screenings than non-users.

WellPoint demonstrated that claims and clinical data can be combined to create an integrated clinical record that supports efficient delivery of care. With the program’s initial deployment, WellPoint and the physicians in the community collaborated to define the clinical rules, and the vendor managed the process.

WellPoint will continue to collaborate with local physicians to manage the clinical rules, while also taking primary responsibility for benefit rules.

Insurers who administer their own health management programs need to plan extensively, says Jackie Mazoway of Pricewaterhouse-Coopers.

Jackie Mazoway
Cover Story

Large PBMs Transform Old Business Models

Urged on by employers, the Big 3 are going beyond traditional pharmacy benefit management, stressing consumer interactions and disease outcomes and threatening the existence of captive PBMs

While the 14–15 percent annual increases in drug expenditures of the early 2000s have settled down to around 5 percent, there are unsettling forces at work within the PBM industry: Three giant pharmacy business managers have disrupted the basic PBM business model, there is increased pressure from employers for benefit managers to perform and to deliver more services, and there is a growing chance that most health insurers will get rid of their in-house PBMs.

Disease management companies might also find they are subject to competition from PBMs with overlapping services.

Some good is coming out of the commotion: Services to consumers have expanded, and attention has switched from dispensing prescriptions to improving medication outcomes.

Differentiating the PBM Market

The Big 3 — CVS/Caremark, Express Scripts, and Medco Health Solutions — aren’t just sitting back and enjoying their dominance. They are throwing their weight (almost half of all prescriptions) around by pursuing business strategies that differentiate them from each and from the rest of their industry.

What HR looks for in a PBM

“Clearly, different models are emerging,” says Steve Miller, MD, who is Express Scripts’ chief medical officer. “The path we are taking is based on our behavior-centric approach,” he says. Express Scripts is developing a niche by becoming expert in consumer behavior related to medications. The goal is to find ways to change behavior that promote optimal use of medications from the point of view of quality and cost.

One approach the company uses is segmenting consumers into categories and using different methods to change each group’s behavior. It has touted a program involving Lowe’s, the home improvement store, where mail service was made standard with an opt-out option. Most mail programs are opt-in, so this approach reversed consumer choice, but Express Scripts says it has been well received, has cut costs, and has improved compliance.

“Benefit designs that eliminate copays increase compliance by 1 to 5 percent, but a company takes on a huge additional expense by absorbing the copay. We found that moving patients to mail is the single most important thing you can do to improve adherence: It increases compliance by 8 percent, and the member saves money.”

Reports say that the most common reasons that patients are noncompliant are that they forget to take their medication, they get better, or the medication seems ineffective. Express Scripts focuses on changing these perceptions and behaviors. Miller says that the company targets asthma, diabetes, and cardiovascular disease.

“The compliance rates for these conditions range from 60 percent to 70 percent, so there is a tremendous opportunity to improve things and to lower medical costs, like ER visits for asthmatics.”

The essence of Express Scripts’ approach is fine tuning of standard techniques: linguistics tailored to specific groups like the elderly or those with little education, timing of messages, and streamlining of home delivery.

Express Scripts’ business model is likely to change somewhat this year with the expected acquisition of WellPoint’s captive (owned by a health plan) PBM, Next Rx. WellPoint will become a dominant customer, with leverage to influence Express Scripts’ services by providing one third of Express Scripts’ total prescription volume. And Express Scripts’ Medicare Part D volume will grow substantially, adding requirements like medication therapy management services.

Medco, the disease manager

Medco is the largest PBM and the universally recognized leader in mail prescriptions. Its mail-order business generated $22 billion in 2008 from 106 million prescriptions. The company claims that its mail volume is more than twice that of its closest competitor. Medco is sticking with this core competency, yet doing new things.

“Medco has a clinical strategy with Therapeutic Resource Centers (TRCs) that it has set up to manage individual medical conditions such as diabetes, cancer, heart disease, and asthma,” says John Malley, national pharmacy consulting leader at Watson Wyatt. The PBM says that 1,100 specialist pharmacists work in these centers.

“The pharmacists are trained in specific diseases, with emphasis on identifying comorbidities and side effects, and on consulting with patients to improve outcomes,” says Luis Salmun, MD, vice president and head of the pulmonary/immunology TRC at Medco.

The essence of the centers is individualized medicine — understanding each patient’s response to medications, medication gaps, right-dosing, and gaps in care, says Lisa Gill, managing director of health care equity research at J.P. Morgan Securities, which has has an investment banking relationship with Medco and CVS/Caremark.

“Medco’s internal research indicated that Medco mail order customers have a higher compliance level than retail customers. This trend is true of many PBMs who own their own mail order facilities, ”says David Dross, national leader of Mercer’s pharmacy consulting practice.

Medco’s mail and disease management strategy was behind its acquisition of Liberty Medical Supply, a mail order vendor of diabetes supplies to Medicare patients; one of Medco’s TRCs is devoted to diabetes. The combination of the diabetes supply business and Medco’s own Part D prescription plans gives the company broad involvement with the elderly, a targeted growth area for PBMs.

Face time

CVS/Caremark, the other member of the Big 3, is betting on retail. It has developed several programs to drive business through the front doors of its pharmacies. “One of the missing elements in pharmacy services is face-to-face interaction between a pharmacist and patients, and this is what CVS is promoting,” says Malley.

The company has implemented a “Maintenance Choice” program in which patients can pick up their 90-day prescriptions at a CVS store instead of receiving them by mail. Patients can also get some specialty medications at the pharmacy, where a pharmacist will answer questions and show how to administer the drug. Earlier this year, CVS won an award from URAC, which accredits PBMs, for its drug therapy management program, which focuses on medication outcomes.

In 2008 CVS/Caremark boosted its storefront strategy by acquiring Long’s Drug Stores, with about 520 stores, and RxAmerica, a PBM with about 8 million members. The company now has more than 6,900 stores, about 10 percent of the nation’s 65,000 pharmacies. The PBM acquisition also added 450,000 Part D members to CVS’s Medicare membership.

Therapy management

The emerging strategies of the Big 3 center on one thing: expanding direct contact with consumers. They see both the need to respond to demands from employers and the opportunity to expand their roles from the administrative function of dispensing prescriptions to include managing patients.

“Employers are becoming more vocal; they are saying, I want accountability and results,” says Larry Boress, CEO of the Midwest Business Group on Health. More specifically: “Employers believe that PBM’s can do a lot more than just fill scripts. They have a great potential to be more active in patient management — not in preventive care, but with those who have chronic conditions, addressing and controlling them early on with the right medications.”

Helen Darling, CEO of the National Business Group on Health, says that “PBMs and the services they provide, including with plans, are very important to employers and having some competition is a good thing. Their innovations, such as Medco’s work with genomics, are very valuable.”

Boress points out that “Clinical programs were an afterthought for PBMs. Now they have come to the forefront.”

MTM blossoms

Medicare is also demanding more through the Part D program, which the Big 3 participate in either as plan sponsors, as administrators of retiree benefits, or by serving their health plan clients. Beginning in 2010, the medication therapy management programs for people with multiple chronic conditions will switch from opt-in to opt-out, vastly increasing the number of participants.

Joseph Gruber, RPh, at Mirixa, which runs a network of community pharmacies linked by a common MTM technology, says this change could increase MTM participation from about 1.4 million to 5.7 million people, boosting the demand for the consultative and therapy management services the Big 3 and other companies that have Medicare Part D plans are now offering.

The Big 3 have recognized that they are in a key position to respond to growing demands for drug therapy management services. Malmun says that they have an existing relationship with patients, who carry their ID cards; that employers promote their clinical programs to employees; that they have data systems that can accurately track medications; and that they have pharmacists who work in an environment that keeps them up to date on medications.

For insurers that have outsourced their pharmacy benefits to a PBM, patients may have more of a relationship with the PBM than with the health plan.

True to the core

While the Big 3 are expanding their services, they are also holding on to the core service that funds their expansion and keeps them in good standing with their clients — increasing the use of generics. And why not? This is a lucrative service.

CVS/Caremark admitted in its latest quarterly SEC filing that generics were important to its bottom line and that they “yield a higher gross profit rate than equivalent brand name drugs.” That is because of the use of spread pricing arrangements, where PBMs purchase generics and mark them up.

The switch from brand drugs to generics saves money for employers and other clients, but it is also good for PBM profits. It has helped to moderate the increase in gross expenditures for pharmaceuticals. PBM clients went from mid-teen increases earlier to 6.9 percent in 2007 and 4.9 percent in 2008, according to the Pharmacy Benefit Management Institute. J.P. Morgan reported a 5.4 percent increase between early 2008 and early 2009.

In the first quarter of 2009, Express Scripts increased its generic fill rate to 67.7 percent from 65.1 percent a year earlier. Caremark increased to 67.7 percent from 64.1 percent, and Medco increased to 66.8 percent from 63.3 percent. According to the Kaiser Family Foundation, the national average price of a generic is $34.34, vs. $119.51 for a brand drug, so the savings to employers from volume shifts to generics are substantial.

In spite of the predominance of generic scripts, they total only 21 percent of national drug expenditures, according to the Kaiser Family Foundation, so there is still an opportunity to save money on brand drugs for employers. That will occur naturally as brand drugs lose their patent protection. That natural conversion will also automatically fuel PBM profits if the current mark-ups continue.

The J.P. Morgan report comments that “generic profitability does not appear to be at risk in the near term,” and says that employers are satisfied with the pricing arrangements they have with PBMs and that PBMs have been able to maintain their margins.

“Margins for PBMs are still intact [for generic drugs] on the retail side,” says John Malley. “Employers may think they are getting a bargain at AWP minus 65 percent, but don’t be surprised if [PBMs] are purchasing them at AWP minus 85 percent. It’s surprising how cheap generics can be.”

J.P. Morgan sees a favorable macro environment for the PBM industry. “Generics will continue to replace brand drugs, changes in benefit designs can further encourage mail order, and specialty pharmacy will continue to grow rapidly, with opportunities for PBMs to help employers control these costs,” says Gill. There is plenty of opportunity for PBMs to improve cost effectiveness in purchasing specialty drugs and in managing specialty drug inclusion in formularies, which will save employers money and yet be profitable for the PBMs, he adds.

Can others compete?

The new business models of the Big 3, combined with their market dominance and technical resources, raise questions about the outlook for captive and mid-market freestanding PBMs.

“Pharmacy benefits are almost an afterthought for health insurers,” says Malley.

“The PBMs devote 100 percent of their attention to the 15 percent of premiums going to pharmacy benefits, while health insurers naturally assign their best people to the 85 percent that represents medical costs,” says Gill, the Wall Street analyst. “It’s very hard for the health plans to compete against the PBMs for that reason.” So captive PBMs get bought by freestanding PBMs.

About $1 billion in business is moved away from health insurers to PBMs annually in that manner, says Gill.

One justification health insurers use for operating their own PBMs is simplifying the integration of medical and pharmacy data to manage patients, says Gill. But she discounts this argument: “Pharmacy claims are adjudicated in real time, so the data are available in a timely fashion.” Gill says the data argument is valid only if health insurers also adjudicate medical claims instantaneously and need to merge the two sets of data immediately. Others say that there are long lags in transferring data to health plans and that timeliness is crucial for their medical management programs.

Boress says the integration of medical and pharmacy data is important to employers who are looking to simplify their analysis of utilization patterns. He says this analysis is more difficult when the data comes from two sources.

The advantages of captive PBMs go beyond the integration of data, says David Lassen, chief clinical officer at Prime Therapeutics, a PBM jointly owned by 11 Blue Cross plans. “Prime aims to be fully integrated with its Blue partners so we understand their health management strategy and tailor our activities to meet those objectives.”

As examples, he says Prime’s benefit designs, formularies, and utilization management programs are more tailored to his owners than the standard approaches of freestanding PBMs. He says his therapy management activities are also better integrated. “Our Blue partners place greater emphasis on holistic health goals involving wellness and chronic disease management. Our therapy management activities are directed to supplement their health management interventions, specifically to lower total health care costs.” While other PBMs do the same thing, Lassen says, the nature of his relationship with his owners improves this coordination.

Other questions about the future of captive PBMs have increased since the announcement of a $4.6 billion deal that will send Next Rx, WellPoint’s PBM, to Express Scripts. During a recent investors conference call, Cigna acknowledged that it is evaluating the future of its PBM. That sale could raise $1.3 billion for Cigna, analysts say. Insurers can fetch good prices for their captive PBMs, stock analysts say.

UnitedHealth Group operates the largest captive PBM but even so, many functions are outsourced to Medco with a contract that extends to 2012.

Smaller freestanding PBMs have a difficult time competing against the Big 3, especially for contracts with large employers. They tend to focus on the next lower tier of employers, and there is extra overhead when you administer many contracts. In addition, they do not have the purchasing leverage of the high-volume PBMs or the depth and breadth of technical expertise.

One strategy that small PBMs use to compete is completely transparent pricing. These companies offer a cost-plus model that passes through 100 percent of rebates and eliminates hidden spread pricing. In exchange, they charge administrative fees for retail and mail order prescriptions and for added services.

Navitus, a PBM owned by Dean Health System, an integrated health plan and provider organization in Wisconsin, administers pharmacy benefits for the state under a cost-plus model that has been successful for the state for a long time in terms of cost savings and customer satisfaction.

“Traditional pricing arrangements often create conflict among employers, PBMs, and drug wholesalers that shortchange the employer,” says Bob Palmer, CEO of Dean Health Plan in Wisconsin. “Transparency pricing models properly align the incentives of PBMs and employers and therefore establish the best kind of working relationship.”

Transparency models have an established niche in the PBM industry because of their straightforward approach. In addition, consumer organizations are lobbying states to enact laws to require disclosure of rebate and discount terms. Maine and Maryland have enacted such laws.

Reluctant to change

One competitive issue for all PBMs is that it is difficult to get employers to switch vendors. “Pharmacy is a sticky business,” says Gill. Employers are reluctant to switch vendors because of the work and cost involved and — more importantly — because of the hassle it creates for employees in learning the rules and procedures of a new company. In addition, the J.P. Morgan survey has consistently shown that employers are satisfied with their PBMs. In the latest survey, 44 percent said they were very satisfied; in contrast, 16 percent said that they were relatively dissatisfied and none at all were very dissatisfied. These factors benefit large PBMs and make it difficult for small ones to grow.

Gill says that the future of all PBMs is tied to change. “The business is not just about dispensing prescriptions. It has moved on to a much broader array of services: to use the most appropriate medications at the best cost, to do the most good for consumers. The model is moving toward expanded services.”

Tom Reinke specializes in health and business topics. Reach him regarding this article at TReinke@ManagedCareMag.com.

For further reading

Academy of Managed Care Pharmacy. Sound Medication Therapy Management Programs, Version 2.0, With Validation Study. J Manag Care Pharm. 2008 January;14:(1 Suppl):S-b. http://bit.ly/2g9cvj

McDonald RC. Managing the intersection of medical and pharmacy benefits. J Manag Care Pharm. 2008 May;14(4 Suppl):S7-11. http://bit.ly/2F1XrJ

Kaiser Family Foundation. Prescription Drug Trends. September 2008. (PDF included) Available at: http://bit.ly/3BwRE5

Pharmacy Benefit Management Institute. Prescription Benefit Cost and Plan Design Report, 2008–2009 edition. Available at: http://bit.ly/1YVNNC

The PBM industry today

The PBM industry consists of about 60 players, including three dominant companies, several mid-market companies (including the captive PBMs of health insurers), and about 50 small PBMs with a combined market share of less than 15 percent.

In 2008, 3.8 billion prescriptions were administered, according to IMS Health. The Big 3 — CVS/Caremark, Express Scripts, and Medco Health Solutions — handled about 1.7 billion of them. This year Medco will process about 700 million, CVS/Caremark will handle about 653 million, and Express Scripts, about 420 million. Express Scripts’ volume will grow to about 690 million with the planned acquisition of WellPoint’s captive PBM Next Rx, according to company SEC filings.

The combined 2008 revenue of the Big 3 was approximately $128 billion, not counting revenue from CVS/Caremark’s retail pharmacy operations.

Among health insurers with captive PBMs, UnitedHealth Group is the largest with 250 million scripts, but many of its functions are outsourced to Medco. A group of Blue Cross plans owns a captive PBM, Prime Therapeutics, which processes 120 million prescriptions. Aetna and Cigna have their own PBMs with volumes of 90 million and 75 million prescriptions, respectively, AIS Health reports.

The emerging strategies of the Big 3 PBMs center on one thing: expanding direct contact with consumers.

Express Scripts’ chief medical officer, Steve Miller, MD, says the company is following “a path based on our behavior-centric approach” by becoming expert in consumer behavior related to medications.

“Employers are becoming more vocal; they are saying, I want accountability and results,” says Larry Boress, CEO of the Midwest Business Group on Health. “PBMS can do a lot more than just fill scripts.”

Prime Therapeutics’ benefit designs, formularies, and utilization management programs are more tailored than the standard approaches of freestanding PBMs, says chief clinical officer David Lassen.

Thomas Reinke

Want to Change Patients’ Behavior? Look to the Internet

Patients are responding to online programs that help them improve or maintain their health and become better consumers

Health insurers face ever-changing expectations from their primary customers — employers — and one challenge that has been tough to meet is getting consumer buy-in on wellness and health promotion. In some cases, employers go around their health plan to vendors that offer new approaches.

“Employers are expecting that health plans and providers will do the lion’s share of the work in motivating employees to be more proactive about health care choices and decisions,” says David Lansky, PhD, CEO of the Pacific Business Group on Health. “Their frustration is that they don’t see this working very well, and health insurance costs keep going up. So they have turned to wellness and disease management companies as add-on services for what they think health plans and doctors should be doing routinely.”

The Center for Health System Change looked at the problems with engaging patients and reported that strategies such as consumer-directed health plans with cost sharing provisions, cost and quality transparency efforts, wellness programs, and disease management programs have had limited success.

Experts say that first-generation efforts by health insurers to engage patients were blunt instruments. Tactics like generic patient reminders, standard-script telephone calls, and dissemination of off-the-shelf educational materials were often viewed by consumers as monitoring or supervising their care, rather than supporting them and encouraging them.

In addition, cost-sharing strategies were criticized for giving patients incentive to forego services and medications instead of choosing cost-effective providers. Also, information to help patients evaluate providers was often irrelevant because it was not specific to the patient’s medical problem.

Yet considerable hope is pinned to greater involvement of consumers in making cost, quality, and utilization decisions about their health care. “Going through the consumer is the last stop en route to any lasting improvements in the health system,” says Lansky.

Consumers must be engaged on three fronts: health promotion, including chronic disease management; making informed treatment choices for acute conditions; and choosing cost-effective providers. That’s a tall order.

Changing behavior

Progress is being made in finding smarter approaches to change health behaviors or manage chronic diseases. Experts say that subjective tactics are giving way to evidence-based approaches and that the Internet is emerging as the vehicle to connect consumers with these approaches. Theories on behavior change have existed for years and several care management companies use them in their health and wellness programs.

One of these new patient-engagement approaches incorporates the transtheoretical model (TTM), which draws from several change theories. Researchers at the University of Rhode Island developed the transtheoretical model beginning in 1979. It incorporates several different theories of psychotherapy, hence the name “transtheoretical.”

A company called Pro-Change Behavior Systems, founded in 1998 by researchers at the University of Rhode Island, has developed an Internet-based behavior change application based on the TTM, called the Lifestyle Management Program Suite.

It has programs for smoking cessation, stress management, weight management, depression prevention, exercise, and medication adherence for hypertension and for high cholesterol. This application has been adopted by several care management vendors as the core of their health promotion programs. “It is an interactive program that guides the user through the five stages of change,” says Kerry Evers, PhD, senior vice president.

The stages are precontemplation, contemplation, preparation, action, and maintenance.

The software is an expert system where pathways to stimulate change are determined dynamically. The software interprets user responses and tailors its next action to that user input.

“The key to the program is figuring what intervention message to give the participant at a particular point in time,” says Evers. “If the program determines that the user has made some changes, it will encourage further changes or reinforce past action based on the science and statistical decision making.”

For example, if a participant indicates that he sought information about a health problem it will reinforce that step and encourage the next step.

The key challenge is to get the participant to agree to change behavior, even if he does not think he is ready for change. “The research shows that for consumers who are not planning to change, one key intervention component is assessing what benefits might be important to them and providing information on those personal benefits,” says Evers.

“The research says that the key to getting buy-in from consumers when they are not planning to change is assessing what benefits might be important to them and providing information on those personal benefits,” says Evers.

“In a clinical trial for our stress management program, 60 percent of participants started effectively managing their stress,” says Evers. These results can be obtained from three interactive sessions, for a total of one to one and a half hours, over a six-month period.

Recruitment is important. “For employers, the culture of the organization, executive level support, quality of messaging to employees, and incentives are all very important,” says Evers. She explains that while there are mixed results on the effectiveness and use of incentives, this is currently a major focus area for the field.

Stanford patient ed

Pro-Change Behavior Systems got the gold in URAC’s 2009 Best Practices In Health Care Consumer Empowerment and Protection awards. John DuMoulin, a URAC VP, says that URAC found widespread use of Pro-Change’s Internet-based transtheoretical model programs.

A slightly different Internet approach has been developed at the Stanford [University] Patient Education Center. It has been working on chronic disease self-management courses for arthritis, heart disease, diabetes, and cancer for 30 years. These courses started as small-group sessions in community settings, often by hospitals. They have been used in 17 foreign countries and in hospitals operated by Kaiser Permanente and Group Health Cooperative in Seattle.

Recently, Stanford developed an Internet version of the courses, following the format of its classroom program. The Internet course is led by an actual instructor, and the participants interact online.

For example, the Internet chronic disease self-management course covers heart disease, lung disease, and type 2 diabetes. The online instructor has one of these conditions and leads group interactions that motivate and instruct participants in behaviors to improve their health.

“Our programs are based upon self-efficacy theory, which says that the strength of one’s belief that he can do something is a good predictor of his motivation and potential for success,” says Kate Lorig, RN, DrPH, the center’s director.

The self-management program teaches people to set goals and manage their health in three areas: medical management, such as medication adherence or diet; role management, which is solving problems, making decisions, and accomplishing goals; and emotional management, which is responding to emotional ups and downs, including depression.

“Negative and problematic emotions are very common and are a major reason that people don’t change their behavior,” Lorig says.

All Stanford programs have been evaluated for effectiveness in large randomized controlled trials before they are released, she adds.

Pro-Change Behavior Systems and Stanford license their products to vendors, and those vendors often package these programs with other services, so information on the cost per participant is hard to determine.

There are limited published results for Internet-based behavior change programs, largely because they are new, as are employer-based wellness programs.

One worksite-based clinical trial compared the Pro-Change TTM programs to two other health promotion strategies — motivational interviewing, and health risk assessment plus intervention. The focus was to determine which interventions helped employees move away from risks such as inactivity, obesity, stress, and smoking.

Significant results

The results at six months showed that motivational interviewing and Internet-based TTM tailored programs both had statistically significant results in meeting risk criteria for stress and exercise. There were no statistically significant differences between motivational interviewing and TTM (Prochaska 2008). The study did not measure changes in the utilization or cost of health care services. Proponents of Internet intervention tout its cost advantage over motivational interviewing.

The Internet is also being used to help consumers with more complex concerns, like evaluating acute care treatment choices. The American Cancer Society (ACS) invites consumers to its Web site to use an interactive decision-support tool that solicits information about their cancer and their preferences and helps them evaluate alternatives such as surgery, chemotherapy, or radiation.

The software is from Nexcura, a health information company owned by Thomson Reuters. The visitors to the ACS site tend to be aggressive information seekers who demonstrate their willingness to rely on the ACS site and the Internet by creating an online account with personal information.

The tool also requires some work from the user. “The first section for a new user usually takes 20 to 30 minutes to complete,” says Alicia Moffat, Nexcura’s VP for operations. “The visitors to the ACS site as a whole are highly motivated; we have found that the drop-off rate is only 40 percent to 50 percent.” In contrast, says Moffat, drop-off can be as high as 80 percent in a commercial site with online tools.

Cigna has been able to get members of its consumer-directed health plans to use online tools to evaluate and select high quality, cost-effective providers.

“Sixty percent of CDHP members have signed up to use our transparency tools; this compares to 30 percent in our HMO and PPO plans,” says Jeffrey Kang, MD, Cigna’s CMO.

“The number of people consulting our online cost comparison tools, which were separate until integrated with Care Connections, has increased dramatically in just one fiscal quarter,” says Kang. “For example, the number of people comparing hospital and/or facility costs for cardiac catheterization increased more than 50 percent.”

“People pricing colonoscopies online increased nearly 40 percent, and those comparing costs for MRIs and CAT scans jumped more than 35 percent,” reports Joe Mondy, assistant vice president for IT communications at Cigna. Cigna reports that 55,000 members visit its Care Connections Web site each day.

Mondy says that Cigna’s tools have become interactive and that information on providers’ fees appears next to information on providers’ quality. Other companies’ Web sites and public sites do not integrate fee and quality information; consumers must go to separate locations to find this information, he says.

Style or substance

“Health insurers have viewed health promotion programs as a marketing tool, so they tend to have gone with things that are sexy or flashy,” says Lorig. “With rare exceptions, they have not gone with programs that are evidence-based.”

Evers shares this view: “There is extensive research on behavior change that is directly applicable to health behaviors and this knowledge has been built into effective programs.”

Lorig also says that insurers have followed a one-size-fits-all approach, “but these are opt-in programs, and when you want people to opt in, you have to offer them choices.”

He adds: “Tailoring is in vogue, but the health plans say, I have learned something about you and I will tell you what you should do. Health promotion or disease management programs need to let participants tailor their goals and the process for getting there. We found that patients are the best judges of what they can accomplish.”

That is the essence of the latest Internet-based programs.

Tom Reinke specializes in health and business topics.

PAM: The University of Oregon’s Patient Activation Measure

The Lifestyle Management Program “guides the user through the five stages of change,” says Kerry Evers, a senior vice president at Pro-Change Behavior Systems.

Researchers at the University of Oregon have developed a tool that measures the level of patient engagement. The Patient Activation Measure (PAM) contains 13 questions that reflect how a person understands his role in managing his health and his confidence for taking on that role. “Activation refers to people’s ability and willingness to manage their health and their health care,“ says Judith Hibbard, DrPH, senior researcher in health policy at the university.

Because the PAM has very strong measurement properties, it is being used to tailor support, education, and communication for individual patients and consumers. The PAM also stratifies consumers into four levels of activation. “At the lowest level, people tend to be passive and they tend to be discouraged about their ability to manage their health,” says Hibbard. At the third level, people appear to be taking some action, but they still lack the confidence and skills to be in control of their health care. At the highest level, people are proactive in managing health problems, but life’s stresses may still overpower their self-management efforts.

Patients who are least activated can be further discouraged and overwhelmed if their provider hands them a long list of behavior changes they need to make. By focusing on reducing their feelings of being overwhelmed and helping them to take one or two small steps toward making changes, a clinician can help the less motivated patient to become more engaged. “But first they have to know where the patient is at. That is where measurement comes in,” says Hibbard. In addition, measurement, in the form of the PAM, can also help to track patient progress. Tracking PAM scores help the clinician know whether or not the patient — or a whole population of patients — is making progress.

A recent study published in the American Journal of Managed Care shows that tailoring coaching to a patient’s level of activation resulted in improved patient adherence, better clinical indicators (e.g., LDL and blood pressure), and significantly reduced ER and hospitalization rates, compared to a group of patients who were coached in the usual way.

Health plans and disease management companies are using this measure to tailor their coaching and communications with patients. In addition, they are using the PAM to more efficiently allocate their resources. For example, they use more intensive resources to reach out to the more passive, poorly activated members with a more personal touch, while they simply push information out to those who are more activated and are ready to use the information. Thus, the PAM is being used to more efficiently allocate resources, to tailor support and education for patients, and to evaluate the effect of efforts to engage and activate patients.

Hibbard points out that it is difficult to determine cause and effect in activation — whether poor health status causes low activation or low activation results in poor health. Hibbard says it is likely that causality goes in both directions.

The University of Oregon has given an exclusive license for PAM to Insignia Health, which offers several PAM-based products, including a tailored coaching program for clinicians and coaches, and a tailored self-guided program for consumers.

For further reading

Initial efficacy of MI, TTM tailoring and HRI’s with multiple behaviors for employee health promotion. Prochaska JO, Butterworth S, Redding CA, Burden V, Perrin N, Leo M, Flaherty-Robb M, Prochaska JM. Prev Med. 2008 Mar;46(3):226–31.

How engaged are consumers in their health and health care, and why does it matter? Hibbard JH, Cunningham PJ. Center for Studying Health System Change. Resolution Briefs. 2008 Oct;(8):1–9.

Do increases in patient activation result in improved self-management behaviors? Hibbard JH, Mahoney ER, Stock R, Tusler M. Health Serv Resolution. 2007 Aug;42(4):1443–63.

Plan design and active involvement of consumers in their own health and healthcare. Hibbard JH, Greene J, Tusler M. Am J Manag Care. 2008 Nov;14(11):729–36.

Does enrollment in a CDHP stimulate cost-effective utilization? Hibbard JH, Greene J, Tusler M. ed Care Resolution Rev. 2008 Aug;65(4):437–49.

“Health insurers have viewed health promotion programs as a marketing tool,” going for sexy or flashy, says Kate Lorig RN, DrPH, director of the Stanford University Patient Education Center.

Thomas Reinke

Modern Cardiovascular Programs Cut Costs, Inpatient Days, and Deaths

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

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/), 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.

Lola Butcher
Contributing Editor