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Self-Funded plan management–take a close look at disease management results February 27, 2012

Posted by medvision in Employee Wellness, health data, Healthcare Costs, Insurance Plans, Risk Management, Uncategorized.
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Recently results of Medicare’s largest commercial disease management study were republished in the New England Journal of Medicine.

This study should refocus plan managers on the issue of disease management because 75% of all plan dollars are spent on chronic disease. Preventing the production of disease and the management of existing disease states is the entire ball game with respect to healthcare. Back to the Medicare pilot. In the Medicare Modernization Act of 2003, CMS was required to test the commercial disease management industries services with respect to the Medicare fee-for-service program. The program engaged eight of the industry’s DM providers, 250,000 Medicare beneficiaries with serious cardiovascular disease and spent $400 million over the four-year program. The conclusion was reported: In this large study, commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality-of-care measures, with no demonstrable reduction in the utilization of acute care or the costs of care.

How should this be viewed in today’s environment? I’ve always felt the practice of nurses calling healthcare members they do not know, usually from a different state while attempting to offer advice concerning very personal aspects of one’s health is very problematic. Why? (1) Everyone, especially working folks, have very limited time during home hours (2) Not many are comfortable discussing their health issues with strangers and (3) nurses calling many times have limited, or worse, incorrect data about the medical conditions associated with the member.

My impressions of commercial disease management reports being delivered to clients today seem to be verified by the Medicare study as having, essentially, no positive results. But, Medicare members are very different from commercial health plan members? Yes in some ways, however they are mainly at home available so members have time to speak with nurse managers, this pilot targeted serious states of disease, and still, no demonstrable reduction. In what ways should plan managers react when delivered industry standard reports?

  1.  Don’t allow a 50 page DM document impress. DM providers have a strategy of creating member silos in which they describe all silo members as participants in the plan. A member not complaining about monthly mailings is “not” a participant! How many of us pitch 3/4ths of the mail we receive in the trash can? Probably over 90%. The only participants are the ones in continuous monthly/weekly phone calls with nurse managers. Usually this class never exceeds 1-3% of total members.
  2. Health claims metrics reported by the DM vendor probably will contain positive results. These must be verified from independent data in order to be considered valid. Many times DM providers attempt to “prove the negative’ by claiming their efforts created an absence of claims. Even worse are “vapor” attempts to prove savings by producing some type of productivity gain metrics! Sorry but this business in not akin to a college philosophy class.
  3. Each year $100s of millions are simply wasted on telephonic DM. If you cannot see the results clearly, the result didn’t happen.
  4. If you are offering a sole HDHP don’t assume a short-term claims reductions are necessarily good news. In today’s economic climate many are forgoing important medical care. As water recedes prior to a tsunami, an absence of claims this year may be indicative of an avalanche of future chronic disease.

Now the good news. If it isn’t working, try another approach. I’ve seen clients spend $250K through $500,000 with no clear results. How about using the dollars to hire, through a vendor/or directly, on site full-time nurses to reach out to members, face to face? People trust others they meet, trust and recognize!

The greatest opportunity in healthcare is for employer purchasers of healthcare to start demanding the results they want/need from vendors. Vendors which perform win should be rewarded and the many failing need to be sent packing!

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Dean Ornish Talks Lifestyle February 20, 2012

Posted by medvision in Uncategorized.
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How many times have you heard 75% of all healthcare expenses are a result of poor lifestyle choices? Dean Ornish, MD,  received his internal medicine training from Baylor, Harvard Medical and Mass General Hospital. Over the past 30 years, Dr. Ornish has become the nation’s leading apostle concerning the healing ability of lifestyle modification for chronic diseases including severe heart disease, prostate cancer and type 2 diabetes. http://tinyurl.com/7qcuf6s

Medicare currently reimburses for his program, Mutual of Omaha found a $30,000 savings per patient and Highmark Blue Cross found heart disease/type 2 diabetic patients cut medical expenses by 50% in the 1st year. His research, clinical trials and lifestyle programs are breathtakingly successful.

Why isn’t this news taking the “at-risk” employer health plan sponsors by storm?

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