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Spiraling medical costs have reached crisis proportions in the United States, with diverse stakeholders - private practitioners, provider organizations, self-funded plans and payers alike - striving to regain control. An answer to the crisis appears to be monitored care and disease management programs.
For years, the insurance industry has driven cost-management initiatives, experimenting with ways to give incentives to patients and providers. Indemnity plans were structured to encourage patients to take care of their health by asking them to bear some of the financial responsibility for a portion of their care, for example. Managed care organizations such as HMOs and PPOs, which offer established guidelines for care delivery, likewise provided incentives to providers by directing patients to their organizations in exchange for acceptance of discounted fee schedules.
Not all successful
Neither approach has proven completely successful at containing costs, and the health industry has refocused efforts on care and disease management programs. Management of chronic diseases was found to cut overall medical costs, decrease frequency of episodes of care and reduce lengths of stay.
The most significant challenge to effective care management, however, has been ensuring that efforts:
1) target patient populations whose outcomes could most significantly impact outcomes;
2) direct workflow so that interventions are delivered consistently and according to accepted standards, and
3) demonstrate acceptable return on investment.
Historically, care management has been reactive rather than proactive. As a result, success varies in management of high-cost illnesses and conditions. When data- and technology-enabled models are developed to address all these challenges, the results improve. Robust and agile software applications, for example, mine data to help identify patients with chronic conditions or who exhibit risk factors for specific diseases. The application can identify individual patients who are not in compliance with care plans or who have not followed self-management alternative behaviors. For example, claims data can show which diabetic patients have not been seen for routine HbA1c and microalbumin tests.
Likewise, software can detect utilization trends within a specific geographic area that affect medical costs. Perhaps reliance on emergency departments and urgent care centers for acute asthma attacks has spiked in a rural area. With this information, payer organizations can design programs directed at patients whose behaviors may result in improved care and medical outcomes.
In addition, data analysis can provide insight into the best use of resources when launching defined care management programs. Is intervention by a registered nurse required, for instance, or will less costly personnel be just as effective?
Health Design Plus began using PROGuide software from SCIOinspire in 2005 to aggregate data from medical and prescription claims. The software serves as one of the tools used in identifying individuals and population groups most likely to benefit from individualized care management programs, as well as where intervention would be most effective. This strategic approach allows plan leadership to tailor plans for specific groups of patients.
Proactive results
The results from Health Design Plus' proactive approach have been significant. Costs at Health Design Plus are increasing at only 50 percent of the national average, attributable in large part to its successful care management programs.
It is apparent that, by more precisely identifying target patient populations and allocating resources best suited for customized programs, organizations greatly increase the effectiveness of care management initiatives. Simultaneously, they become equally effective at managing costs. HIE
Mr. Strickland is CIO at Health Design Plus, a Hudson, Ohio-based company that provides integrated care management, network development and management, claims management and benefit support services.
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