In recent years, a growing number of forward-thinking employers have taken a more up-front role in providing chronic care management to their employees.

The reasons for this are simple: Chronic conditions reportedly account for 25% of all medical costs, and an employee with a longstanding illness can mean higher health care expenses and lower productivity.

To tackle this challenge, a variety of chronic care management programs have been implemented, but with mixed results.

Some employers contract with their insurer or an outside vendor to have a nurse occasionally call employees suffering from chronic illnesses to, for example, remind a diabetic to have a regular blood test.

With the more effective programs, employees receive coordinated care from specialists who design programs that prevent small health issues from developing into full-blown health crises.

With these programs, patients experience better health and avoid costly emergency room visits, hospitalizations, and other major medical episodes. Companies that offer chronic disease management at onsite clinics see their health care costs decrease significantly.

The key to success with any chronic care management program lies in effective coordination, coupled with powerful data analytics that allow employers to induce their employees to take an active role in their own health care.

This approach uses health and wellness reimbursement to transform member data into actionable information, create insights to target root causes of poor outcomes and high costs, design programs that empower consumers and improve outcomes and create provider incentive to support behavior.

The focus should be on five key areas:

1. Controlling costs by improving health status of members

2. Utilizing claims, lab and pharmacy data to identify opportunities to improve member health status

3. Applying medical management processes to the population

4. Selecting individuals who will benefit from intervention

5. Incentvizing providers to participate in the process

The best way to do all this is to join forces with a health management partner

Choosing a partner

By partnering with a health management firm that utilizes data analytics, employers can readily access the type of comprehensive data that is essential for preventing and managing chronic disease.

An experienced firm with specialized expertise can also assist in claims adjudication and payment while providing services such as access to preferred provider networks, prescription drug card programs, utilization review and the stop-loss insurance market.

Going a step further, health plan management firms provide data about health risk analyses and gaps in care to spur programs that change individual health behaviors.

Health management programs are most effective when they include incentives to promote employee participation and compliance, and when senior management fully supports the program by providing ongoing promotion and education.

To leverage this, employers need a broad array of data that can be stratified and analyzed through various parameters, such as pharmaceutical utilization, labs results, inpatient/outpatient days, doctor visits, and potentially disability, workers' comp, absenteeism and presenteeism.

The health management partner should employ robust data analytics to give employers a comprehensive set of utilization data to support decisions related to streamlining inefficiencies. Look for five characteristics:

1. Access to a broad provider network

2. Predictive modeling analyses

3. Member outreach programs

4. Provider outreach programs

5. Integrated solutions that include claims adjudication, eligibility management, and client/customer service

The ability to personalize medical care allows patients and physicians alike to make better health care decisions and tailor preventive, wellness and treatment methods.

Data analytics also provides decision-support tools, remote monitoring tools, and real-time care when it is needed, based upon the philosophy that effective care continues even after the patient leaves the doctor's office.

Employers should also look for a health plan management partner that offers a data analytics tool that:

* Evaluates health data securely

* Analyzes all available hospital, medical, pharmacy and lab data available for a population

* Identifies key health issues for the company and categorizes at-risk members

* Compares previous health costs to future projected health care costs

* Assists in the development of a wellness plan to address key health issues

Additionally, this tool can provide a platform for developing a wellness strategy for each specific at-risk member to help members improve their health and reduce costs. If members opt-in to their personal program, a health advocate can be assigned.

In conjunction with many online resources, members should be encouraged to proactively address their health issues and use their medical benefits to the fullest extent.

The best chronic care management programs are designed to help employers identify:

* Doctor treatment inertia via appropriate protocols

* Patients who are non-compliant with medications

* Patients that need lifestyle/behavior modifications through claims and self-assessments/health records

This process aims to improve the health status of the population, contain health care costs, and incentivize providers to participate.

Case management

In chronic care management, the key principles of case management involve enhancing the general practice team role through a multidisciplinary approach that provides proactive care to patients in the community with the highest burdens of disease, works across boundaries and in partnership with secondary care clinicians and social services, and stratifies patient population to identify patients who are at high risk of unplanned admissions to hospital.

Professional - usually clinical - case managers who develop a personalized care plan on the basis of the needs, preferences, and choices of the patient can provide proactive and seamless support through all parts of the health and social care system.

The benefits for patients include:

* Preventing unnecessary admissions to hospitals

* Reducing lengths of necessary hospital stays

* Improving patient outcomes

* Improving patients' ability to function and quality of life

Aggressive and meaningful chronic care management strategies are quickly becoming the norm among successful companies across the country.

This collective effort promises to eventually improve health and lower costs. Future generations will reap the benefits on a number of levels, especially in terms of seeing the diminishment of costly, debilitating, and preventable diseases.

Employers must revamp their reimbursement models to providers by incenting behaviors - of both patients and physicians - to encourage better health management.

Additionally, long-term success depends on investment in effective technology that can provide a clear health picture of a population. Such information allows providers to identify gaps in care and influence individual behaviors. -E.B.N.


Joseph Berardo, Jr., is CEO and president at MagnaCare, where he's responsible for the strategic management and financial performance of MagnaCare's business operations. He can be reached at 212-867-3606.

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