Preventive Medical Management Techniques

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This is the ninth article in the Medical Management "Signature Series" by Managed Care Resources, Inc. -- articles on topics in managed care written by experts in the field. The author of this article is Roberta L. Carefoote.

Managed care was founded on the principle that a marriage between primary and preventive care would reduce the need for costly chronic care. Nowhere is that principle more prevalent than in the execution of select medical management strategies. According to LaPensee¹, the key to reducing costs in medical management is the prevention of crises that require hospitalization, or the prevention of the onset of disabilities that require long-term expensive services. He posits three levels of prevention that serve as the foundation for discussing key preventive medical management techniques:

• Primary prevention - avoiding increased disease risk through the improvement of health habits. Techniques used in primary prevention include health risk assessments and health education.

• Secondary prevention - avoiding the occurrence of the acute phase of a disease once a patient has been diagnosed with it. Techniques employed in secondary prevention also include health risk assessments as well as disease management and nurse triage.

• Tertiary prevention - avoiding patient decline or worsening of a serious patient condition. Techniques used in tertiary prevention also include disease management.

This article focuses primarily on preventive medical management techniques commonly employed by managed care organizations - health risk assessment, health education, nurse triage, and disease management. While these techniques have been in existence for many years, there appears to be a resurgence of their importance as MCOs struggle to differentiate themselves in the marketplace and employers become more aware of their value and ask for them when selecting health plans. Each technique is outlined briefly discussed in this article.

Nationally, employers devote approximately 95 percent of health benefit expenses to treating illness. They want to decrease these costs by shifting more resources to preventive care and health promotion efforts. According to a Mercer study, only about 15 percent of the working age population is ill at any time, while the remaining 85 percent is either well (20%) or at risk of developing future illness (65%)².

It is that 65 percent of individuals "at risk" that interests employers and MCOs alike. Performing a health risk assessment can identify these individuals. The assessment tool is designed to "elicit information from a member regarding certain activities and behaviors that can influence health status".³ Self-reported information on behaviors such as smoking, drinking, eating, driving, and exercise habits, is obtained via a computerized questionnaire. The results are then put through a computer program to produce a personalized profile of the member's health risk, and a list of what behavior modifications are necessary to improve that person's life expectancy.

The number and type of health risk assessments available in today's marketplace is staggering. You can secure health risk assessments for general populations, for specific age groups or gender designations, as well as for specific health or environmental conditions. The cost of the tool is nominal compared to the costs of administering the survey, collating the data, and acting on the results. One of the key challenges for MCOs is determining who should undergo a health risk assessment, and the frequency of conducting the assessments. Regardless of the populations to be surveyed, the process of responding to the results seems similar.

Upon completion of a health risk assessment, results from the health risk assessment are generally shared with several individuals:

• The member - who is supplied with a copy of his/her personal profile along with a computer generated list of activities that can reduce risk status

• The primary care physician - who also receives a copy of the results so that he/she can better plan future medical interventions

• The care manager - who reviews the information with an eye to identifying specific health education or intervention opportunities. The care manager is also likely to identify specific individuals who are suited to the MCO's disease management program or other health promotion activities.

• The health promotions coordinator (if one designated at the MCO) - who receives an aggregate copy of the results in order to plan and effectively target specific health promotion programs and activities

• The employer - who should also receive only aggregate data, with an analysis of the results and corresponding recommendations.

The objective of the health risk assessment is clear: Identify those individuals at risk of illness or hospitalization, and take action to reduce health risks or prevent illness.

For many years, MCOs have provided nurse triage services in an attempt to educate members, reduce unnecessary medical costs, and provide a value-added service for members and employers. Now commonly referred to as nurse advice lines, nurse triage services can be housed internally with health plan nurses or contracted externally with one of the many commercial services available. If a commercial service is utilized, the MCO needs to ensure a strong link to the medical management department of the health plan. Benefit interpretation and the direction of members to medical services must be in sync with MCO policies and procedures to ensure consistency and appropriateness in member responses.

In addition to speaking directly with a nurse about a health concern, nurse advice lines often provide taped messages pertaining to health issues of interest to the member population. These educational programs can reduce the administrative costs of the service while still meeting the basic informational needs of the members, who call the designated number and are directed via prompts either to the appropriate taped message, or to a nurse.

The hours of operation are almost always extended past usual business hours and in most cases are available 24 hours per day. Important to the success of nurse advice lines is making their availability widely known and providing easy access. Handy refrigerator magnets, business cards, and repeated references in member newsletters will help to get the message out to members. For MCOs with a large geographic area, a toll free number often ensures ready access to members.

Depending on the member demographics, the nurse advice lines can be tailored to address the specific needs of select populations. For example, if the MCO has a large Medicare population, the nurse advice line can focus on the special needs or concerns of the elderly and go a long way to meeting the information needs of this group. A key benefit of nurse advice lines is the opportunity to collect specific data about the informational needs of members. This data can then be used to develop new educational programs, member newsletters, taped messages, or other select interventions.

One of the outcomes of higher health care costs has been the involvement of employers in helping their employees take some responsibility for their health.⁴ It is also for this reason that employers are looking to their health plans as partners to provide some of these health education services--especially at the work site. Work site health promotion is seen to be a particularly effective way to reach people at high risk, and provides a convenient setting for educating and offering the peer support needed to start and maintain healthy habits². MCOs see health promotion and education as a way to differentiate their health plans from others and to create a value connection with consumers and employers⁵.

The cost impact of health education/promotional programs is not to be ignored. Using a combination of a managed health care plan and work site health promotion, the City of Birmingham was able to hold down the increase of medical care expenditures over a five year period. Medical costs increased 1.4% over the five years compared to 11-14% increases for other employers in the area. Since other employers also enrolled their populations in MCOs, the key difference in success was reported as being the inclusion of a comprehensive work site health promotion program2.

Recognizing the value that employers are placing on health education and promotion, MCOs are moving to develop initiatives that speak directly to this need. Interestingly, employees are also placing higher value on work site wellness and health promotion. In a 1995 study by the International Society of Certified Employee Benefit Specialists, wellness and health promotion ranked 10^th among 30 top employee benefit health priorities of employers².

The cost impact, the value to employers and employees, the ability to differentiate one MCO from another, are but a few of the reasons why MCOs increasingly emphasize their health education and promotional activities. The more common promotional programs focus on those conditions that place employees or individuals at risk of illness or hospitalization. In a study conducted by Chrysler, persons with elevated risks in the following behaviors generally used more medical care than their low risk counterparts² -

	· Smoking	· Weight control	· Exercise
	· Alcohol use	· Driving habits	· Eating habits
	· Stress management	· Mental health	· Cholesterol control
	· Blood pressure control

This list serves as a starting point for the selection of basic health education programs. Once developed, the programs can be delivered at the health plan, at the work site, or at easily accessible community sites such as community centers, shopping malls, and skilled nursing facilities. Regardless of the setting, the objective is to get members to identify and change high risk (and high cost) behaviors, and to educate them on the benefits of healthy behavior. It is critical to the continuing success of health education programs that their effects be well documented. Proof of the effectiveness of health education interventions is needed in order to justify existing and new programs, and to partner with employers in underwriting the costs of developing and implementing these programs.

Information to members to help them make better health care decisions can also be classified as health education. MCOs typically handle self-care information in one of three ways: a) a member newsletters with medical advice, b) a self-care guide provided by the health plan that is written in easy-to-understand language and provides step-by-step advice for common medical conditions, and c) nurse advice lines that provide members with access to advice regarding medical conditions or the need for medical care. These self-care programs have been evaluated since the early '80s with typical results being around $2.50 - $3.50 saved for every dollar invested.³

"Congestive Heart Failure patients enrolled in an innovative disease management program experienced an 83 percent decrease in hospital admissions ... and a 44 percent improvement in quality of life...".⁶ These kinds of statistics quickly capture the attention of MCO leaders. And, they are statistics that are not uncommon when it comes to disease-based management in managed care.

Disease management is a widely used term in the managed care industry for the labeling of a variety of care approaches. For the purposes of this article, the definition used by Kongstvedt³ seems appropriate. Disease management is a prospective disease-specific approach to delivering health care, that spans all encounter sites, and augments the physician's visits with interim management through non-physician specialists in the target disease. (E.g. nurses, social workers, health care aides, health promoters, etc.).

Some MCOs would argue that with their emphasis on prevention and comprehensive care, they are ideal treatment vehicles for those who suffer from chronic disease.⁷ Consequently, the focus of disease-based care generally centers on chronic conditions that are characterized by ... ¹

• long duration after onset.

• need for coordinated treatment across a continuum of treatment settings, ranging from inpatient hospital facilities to the member's home.

• high cost per episode of care.

• level of technology or special expertise required for treatment.

Conditions suited to disease management include cancer, heart disease, musculoskeletal conditions, hypertension, depression, asthma and emphysema, diabetes, trauma, and auto-immune diseases. These conditions have had the most success because they³ a) are high cost and high volume, b) have a high rate of preventable complications, c) have disease episodes that lend themselves to discrete coding boundaries, d) have high rates of member non-compliance with treatment regimes, e) have high rates of treatment variability, f) have generally accepted national practice guidelines, g) have general consensus on what constitutes "good" care and how that care should be measured, and h) have interventions that are readily available in most communities.

Common features of disease management programs include:¹

• Guidelines for physicians and other professionals for the optimal treatment of targeted conditions;

• Risk sharing or case management agreements between payors and specialist groups;

• Programs for monitoring the use of specific drug and other treatment interventions to assess patient outcomes and cost;

• Educational incentives to increase members' knowledge of their conditions and doctors' understanding of the most cost-effective treatments; and,

• Interventions to modify both members' behaviors so that they comply with drug and other treatments, as well as physicians' behavior so that they comply with efficacious practice guidelines.

Preventive medical management techniques frequently differentiate one MCO from another and help employers and consumers select a health plan suited to their particular needs. The value of medical management techniques is clear when one examines the cost savings associated with these interventions. More importantly, preventive medical management emphasizes the long-term value and quality of care that prospective members should associate with MCOs. It rightly focuses on the positive aspects of managed care and minimizes the perception that MCOs are more interested in the bottom line than in member outcomes. Perhaps MCOs would be advised to spend more time talking about their preventive medical management techniques, and less about their traditional utilization management activities.

For more information on Managed Care and Quality Management please contact us at (630) 325-6543 or by email at info@mcres.com .

We hope that you will join us as we explore all of the elements of medical management in the coming months. In addition, we are offering a "Signature Series" on "Managed Care Contracting". We hope that the two series combined will lessen the mystery of managed care and help level the playing field between providers and payers.

Ira H. Rosenberg

President, Managed Care Resources, Inc.

References:

1. Kenneth T. LaPensee, "Pricing Specialty Carve-Outs and Disease Management Programs under Managed Care", Managed Care Quarterly, Spring, 1997, pp. 10-19.

2. _________, "The Benefits of Worksite Health Promotion", Association for Worksite Health Promotion (AWHP), http://www.awhp.com, 1997, pp. 1-4.

3.Peter R. Kongstvedt, "The Managed Health Care Handbook - Third Edition", Aspen Publishers, Gaithersburg, Maryland, 1996, Chapters 17 and 20.

4.Monica Gallagher and Mike Jurs, "Healthy or Not, Workers See More Employer Interest, Intervention", Hewitt Associates LLC - Newsstand, http://www.hewittassoc.com, 1997, pp. 1-3.

5.Robert S. Mayo and Sandy J. Rebitzer, "Which Do You Prefer: Grilled McHealthplan or Flame-broiled Wellness King", Managed Healthcare, May, 1997, pp. 26-32.

6._________, "Disease Management Program Results in 83 Percent Decrease in Hospital Admissions and Improved Quality of Life for Congestive Heart Failure Patients", Individual, Inc., December 11, 1997.

7.David Volz, "Incurable Illness in Managed Care", Managed Healthcare, April, 1996, pp.40-42.

The Managed Care Resources, Inc. team has over 150 years of combined experience in the development and implementation of managed care services. Please visit our home page to learn more about how we can assist you with your managed care needs. We also invite you to contact us with questions or comments.

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