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EMPLOYERS ARE DEMANDING a lot from their health plans these days. Chief among these demands are improving the quality of care, keeping costs affordable, supporting employers' workplace health initiatives and educating employees to take a greater role in their own health care. How is the managed care industry responding?
Managed care has long emphasized the twin goals of preventive medicine and appropriate care. Through a variety of strategies -- ranging from utilization review and case management to funneling specialty care through primary care gatekeepers -- health plans have sought to provide quality care to large populations of members.
While reducing unnecessary medical procedures and hospital admissions, these quality initiatives also brought cost-effectiveness to the fore, a concept long missing from the fee-for-service health care delivery system.
Managed care is entering a new phase. Like other industries in the competitive 1990s, managed care companies are using innovation to meet the needs of their customers.
One result is a new approach to delivering care known as "medical care management." Going beyond traditional utilization management, medical care management is driven by the wealth of detailed clinical information now available at health plans' fingertips thanks to recent advances in information technology.
Medical care management, as its name suggests, is a critical change in emphasis from managed care. Cost efficiency is not at the root of the process but occurs as the result of focused prevention, early detection of disease, coordinated treatment processes and the collection and analysis of vast amounts of claims data converted into clinical information.
Recall that the traditional indemnity insurance model centered on waiting for a sick employee to contact a doctor or visit the hospital emergency room. Medical resources were typically focused on managing episodes of acute illness and hospitalization.
Under medical care management, however, promoting wellness and preventing disease is elevated to the same plane as treating illness. Care management seeks to manage care globally -- from prevention through treatment and recovery. It aims to meet both employer and employee needs by improving the overall health status of populations, one individual at a time.
The care management approach also seeks to provide physicians with information that will help them identify patients at risk for disease and that will help them provide the most appropriate level of care for their patients. The goal is to work with physicians to achieve quality outcomes, not to look over their shoulders and second-guess them.
Care management also supports employers' workplace health initiatives to foster employee health -- such as wellness programs -- which reduce absences from work; increase productivity; and, ultimately, help the bottom line.
What kind of cost impact can this have? Unhealthy lifestyles cost America $188 billion in health care expenses annually.
The savings in insurance premiums from just one employee quitting smoking average $1,100 per year, according to studies by Johnson & Johnson and the University of Michigan.
Care management differs from disease management. Care management targets those employees with high-cost chronic conditions, such as asthma, diabetes, cardiovascular diseases and hypertension. These cases are the major cost drivers in the medical delivery system.
That may sound very much like what's commonly called "disease management," which is partially right. Both care management and disease management seek to effectively identify and treat chronic conditions, thereby promoting quality outcomes and controlling costs. But while disease management stops there, care management focuses on the entire spectrum of health status among enrollees -- from the healthy to the sick.
For example, a care management program might identify a population of healthy women within the fertile age range and ask them, on a confidential basis, whether they are planning a pregnancy within the next year. For those who are, records will be checked to ensure that immunizations are current. Additionally, they will get advice about the benefits of folic acid supplementation and the dangers of smoking and drinking alcohol.
Under a care management approach, all employees -- healthy or otherwise -- may be asked to fill out health risk assessment questionnaires to help identify those at risk for disease.
With the employees' consent, the results of the assessment would be provided to their primary care physicians, who can use that information to counsel them on taking preventive steps and making lifestyle changes.
Those employees suffering from chronic disease would be trained in self-management and treated based on the best medical practices currently available -- the disease management component of care management. Thus, disease management is just a part -- albeit an important part -- of care management's broader approach to health care delivery.
Care management differs in a fundamental way from disease management because it is based not on a particular drug protocol or therapy but on managing the care of all enrollees. In its initial stages, disease management programs were designed primarily by pharmaceutical companies to encourage early drug intervention with the twin goals of controlling employers' costs and promoting products.
Not surprisingly, as these programs evolved, they came to rely heavily on drug therapies to control symptoms and head off complications. Hence, the disease states targeted most frequently by disease management programs, such as asthma and diabetes, are those most responsive to drug-based treatments.
Without question, many asthma and diabetes management programs have demonstrated they can improve quality while reducing costs. Harvard Pilgrim Health Care's pediatric asthma program, for instance, cut inpatient admissions by 86% and emergency room visits by 79%. And CIGNA's Lovelace Health Systems has experienced an 83% decline in lost school, day care and work days among children with asthma and their parents.
But what about musculoskeletal and other high-cost conditions that respond minimally, if at all, to drug therapy? Care management can make a difference.
Low-back pain, for instance, is potentially a highly preventable and controllable affliction that affects millions of people each year.
The combined cost of the medical resources used to treat this condition plus the lost work and productivity stemming from it total several billion dollars annually.
A large chunk of those dollars is spent on surgery and X-rays that, according to the low-back pain guidelines of the federal Agency for Health Care Policy and Research, have no proven value in producing better outcomes.
Now consider how a care management program for managing low-back pain performs. A care management program for low-back pain starts by identifying who is eligible by using information technology.
Multiple data sources are pooled and analyzed, including claims and pharmacy data, diagnostic and procedure codes, lab reports and demographic information. Health risk assessments and 24-hour telephonic health information lines are other potential sources for patient identification.
Once identified, patients receive the appropriate intervention from their care manager, based on the severity of their condition.
Primarily, patients are educated on how to avoid further episodes of low-back pain. For uncomplicated back pain, they may be advised to take pain medication, see a chiropractor briefly and maintain normal activities as tolerated. Resources include educational materials and health information lines in which employees can speak in person with nurses or listen to audio tapes about back pain.
On the physician side of the equation, the goal is to better educate providers about low-back pain, ensure effective care and reduce wide variations in practice patterns.
Physicians are provided with clinical practice guidelines from respected scientific sources such as the AHCPR and brief recommendations from peer-reviewed clinical literature about effective ways to treat back pain.
Additionally, data is fed back to physicians on their clinical performance and whether they are following the guidelines. Physicians can use this important information to gauge and improve treatment of their low-back pain patients and to see at a glance how their practices compare with other physicians.
Although still in its infancy, care management shows great promise for improved prevention and patient self-care, reduced variations in practice patterns among providers and lower costs resulting from a decreased need for tertiary-level care.
As a model for delivering health care, care management is being used by health plans to treat an expanding range of conditions. Among the conditions that offer significant opportunities for improved outcomes and cost-effective care are diabetes, asthma, low-back pain, high-risk pregnancies, depression, breast cancer, HIV/AIDS, pneumonia, strokes, congestive heart failure and allergies.
Dr. Victor Villagra is vp-quality and care management for CIGNA HealthCare in Bloomfield, Conn.