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Incentives back plan’s management program
Patients, endocrinologists earn rewards
Case managers at Oxford Health Plans have a new set of tools to help noncompliant members in the plan’s diabetes disease management program.
The case management program, for Oxford’s diabetics with the highest risk of complication, is backed by a gift certificate incentive program for members who see an endocrinologist; the plans’ Best Practice Network of endocrinologists who are certified in diabetes care; and outbound calls by nonclinical staff who offer to make appointments with specialists.
Oxford Health Plans, based in Trumbull, CT, has had disease management programs for about nine years. About 3,000 of its 35,000 members with diabetes who face the risk of complications or already have complications of diabetes are assigned to a case manager.
Members whose diabetes is well controlled with no complications are stratified as lower risk and receive educational materials on a regular basis from the health plan.
Those members and their physicians receive regular reminders when blood sugar tests or retinal examinations are needed.
The revamped disease management program for high-risk diabetics was rolled out last spring.
High-risk members are assigned to case managers who educate the members about their disease and the importance of complying with their treatment plan and call them at intervals determined by the severity of the illness, noncompliance issues, or other problems going on with the members.
The redesigned program helps facilitate getting members to see a specialist and encourages specialists to see Oxford’s most severe diabetics.
The Medicare population as well as the commercial population is in Oxford’s diabetes disease management program.
“We are encouraged by the receptivity to the initiative, but it will take another nine months to assess results of the program in terms of blood sugar control, hospitalizations, and emergency room visits. We believe we are going to see improved clinical outcomes and reduced cost trends,” says Alan Muney, MD, MHA, executive vice president and chief medical officer for Oxford Health Plans.
“Case managers with the right interventions are what it’s all about. They establish a relationship with members, educate them through telephone calls, and encourage them to get testing. Now we have another set of tools for when they run up against barriers to facilitating appropriate care for our members,” he says.
The plan, which covers 1.5 million people in New York, Connecticut, and New Jersey, launched an initiative last year to identify barriers to care and close the gaps in care for the most severely ill members after an analysis of data on the members in the diabetes case management program showed some alarming results.
About two-thirds of members with a hemo-globin A1C greater than 9.5% and a significant number with levels above 11% had not seen an endocrinologist in a year.
“Despite the fact that we had evidence of them having significant diabetic illness, lab tests that chronically showed poor sugar, or hospitalization or emergency room visits for complications of diabetes, they had not seen an endocrinologist,” Muney says.
The health plan carefully examined its data in an effort to understand what was going on. Their study found two primary reasons: 1) members fail to comply with physician orders and physicians are not aware of it; 2) physicians don’t follow clinical practice guidelines surrounding diabetes care, such as how often a patient’s blood sugar levels should be tested and how often they should get retinal examinations.
“We found there were multiple problems and multiple potential for slips in the system,” Muney says.
Oxford’s physicians and members of the quality management department called the primary care physicians. The case managers called the members.
“We told them our records showed that there was a large gap in care between the level of illness the patient shows and the amount of specialist involvement. We asked the physicians, the members, and their families what we could do to help because the evidence shows that the member’s blood sugar is not in control,” Muney says.
Part of the problem turned out to be fragmentation of the health care system, he adds.
In many cases, the physicians had recommended a visit to a specialist, but there was no follow-up to find out if the patient saw the specialist.
“The primary care physicians don’t see the patients that often. It could be two years before the members decide to come in for a visit,” he says.
The same was true of recommendations to get their blood tested for blood sugar levels. Either the physician didn’t order the test, the patient didn’t have it done, or the physicians didn’t get the lab results. In many cases, the physician told Oxford he or she didn’t get the lab tests and didn’t know the blood sugar was not in control.
When the health plan called its high-risk diabetic members, many of them said they knew they should see an endocrinologist but just hadn’t gotten around to it or that transportation problems or other social issues interfered with the visit.
“Part of it is that people don’t understand the serious nature of not controlling blood sugar,” Muney points out.
“There are a lot of reasons for patient noncompliance or physician noncompliance. In many cases, it may look like the physician isn’t following guidelines when in actuality, the patient isn’t compliant,” he adds.
The plan set out to educate both the primary care physicians and the members about the importance of specialist care for diabetics.
“We wanted to determine what incentives we could give the member to see a specialist and if we were going to go out of our way to get members to be compliant, what specialists were the right people to treat our patients,” Muney says.
The health plan sent letters to all of the endocrinologists with whom they had contracts and followed up with a telephone call.
The plan offered to pay for the endocrinologist to become certified by the National Committee on Quality Assurance for diabetes care.
Once the physicians were certified, the health plan agreed to give them extra compensation for caring for the most severely ill diabetics. “Having these specialists care for our sickest diabetic members was such an important part of this initiative that we believe paying for the certification and providing additional fees is appropriate,” he adds.
One of the keys to a successful disease management program for high-risk diabetics is helping the members make and keep an appointment with a specialist, Muney says.
Oxford began an outbound call campaign by staff at its customer service center, to persuade people to see an endocrinologist.
The callers, nonclinical staff who are supported by clinicians, tell the members that they have spoken with their primary care physician and noticed that the member hasn’t seen a specialist as recommended. They suggest a physician near the member’s home and offer to make an appointment for them.
“This is a specialized team that is educated on how to make the calls. They have resources they can call on the clinical side if there are other issues,” Muney says.
The health plan uses staff at its service center because they can call members earlier in the morning and later in the evening when working people are at home and more receptive to telephone calls.
The health plan’s social workers follow up when members have transportation issues and other problems that kept them from getting to the physician.
“These are the things that the primary care physicians don’t have the resources to do,” Muney reports.
When Oxford gets claims data showing that the member has seen an endocrinologist, it sends the member a $50 gift certificate from American Express. “We’ve had a very high success rate. In one week, the callers got 80 of these patients into appointments. We are very happy about that,” he says.
“It is a win for the primary care physician because it helps their patient get the care they did recommend in most instances. The primary care physicians have been very supportive,” he adds.
Members like the program as well, Muney says.
“The callers tell them they know it’s difficult for people to get to doctor appointments and Oxford wants to provide the gift certificate as an extra incentive. People are actually engaged around it. They are amazed that their health plan is calling and trying to get them to spend its money,” Muney says.