Improving Care Through Prevention, Coordination and Management

Transcription

1 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Blue Cross ad Blue Shield Pla Iitiatives to Improve Care for People with Medicare February 2007

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3 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Table of Cotets Executive Summary 2 Itroductio 4 Blue Pla Profiles 7 Blue Shield of Califoria: Cogestive Heart Failure 8 Highmark Blue Cross ad Blue Shield, Pesylvaia: Colorectal Cacer Screeig 10 Highmark Blue Cross ad Blue Shield, Pesylvaia: Improvig Outcomes for Medicare Members with Diabetes 12 Highmark Blue Cross ad Blue Shield, Pesylvaia: Improvig Osteoporosis Maagemet 14 Idepedece Blue Cross, Pesylvaia: Coectios sm 16 Blue Cross ad Blue Shield of Massachusetts: Blue Care Coectio for Heart Failure 18 Blue Cross ad Blue Shield of Michiga: Iitiatives to Improve the Health of Medicare Advatage Beeficiaries 20 Blue Cross ad Blue Shield of Florida: Seior Care Solutios 22 Blue Cross ad Blue Shield of Miesota: SecureBlue a Medicare Advatage Special Needs Pla 24 WellPoit Athem Blue Cross ad Blue Shield: Care Maagemet for Members Livig with Diabetes 26 Medicare Advatage: High Overall Quality 28 Coclusio 29

4 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Executive Summary Oe of the greatest challeges facig the Medicare program is maagig the care for the icreasig umbers of beeficiaries with chroic illesses. A study by Ke Thorpe of Emory Uiversity traced virtually all growth i Medicare spedig from 1987 to 2002 to a 20 percet icrease i the share of Medicare patiets receivig treatmet for five or more coditios ad predicted that the factors resposible for this growth are likely to cotiue. Eighty-two percet of Medicare beeficiaries have at least oe chroic coditio ad 65 percet have multiple chroic coditios ad accout for 95 percet of all Medicare expeditures. 1 Some of the most costly ad prevalet chroic diseases, such as heart disease, diabetes, chroic obstructive pulmoary disease, asthma, ad heart failure, are also oes where adverse evets ca be avoided with better maagemet. The traditioal Medicare program faces sigificat challeges i maagig care for those with chroic illess. Accordig to a report by the Istitute of Medicie (IOM), traditioal Medicare delivers care that is ofte fragmeted as patiets move amog differet physicias ad care settigs, ad does little to ecourage coordiated, prevetive, ad primary care that could save moey ad produce better health outcomes. 2 For the 8.3 millio beeficiaries erolled i Medicare Advatage (MA), a sigle etity is resposible for providig coverage of all beefits. MA plas provide traditioal Medicare beefits plus supplemetal coverage i a comprehesive pla whose reimbursemet structure ecourages a focus o prevetio ad care coordiatio, reduces fiacial barriers to care, ad creates a eviromet that fosters quality care ad satisfactio amog members. Medicare Advatage plas have ogoig iitiatives to improve care for those with chroic coditios. MA plas idetify ad provide support to those who could beefit from more specialized care or who have ot received recommeded prevetive care. Through parterships with physicias ad other caregivers, MA plas work to coordiate ad improve care for these beeficiaries. The Natioal Committee for Quality Assurace s State of Health Care Quality 2006 documeted sigificat quality improvemets i Medicare Advatage plas across multiple health coditios, icludig improved treatmet after heart attack, improved colorectal cacer screeig rates, ad icreased umbers of members whose high-blood pressure is cotrolled. 3

5 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet The profiles i this report describe examples of the iovative ways that Blue Cross ad Blue Shield Medicare Advatage plas are improvig care for Medicare beeficiaries: Blue Shield of Califoria s Cogestive Heart Failure Program is coordiatig care through a team of physicias ad urses usig special home moitorig equipmet. The program reduced expected ipatiet admissios ad emergecy room visits i 2005 by about 20 percet. Highmark Blue Cross Blue Shield s Colorectal Cacer Screeig Program icreased screeig rates by over 9 percet from 2003 to 2005; its Osteoporosis Maagemet Program had a 9 percet icrease i members receivig maagemet services after a boe fracture; ad its Diabetes Disease Maagemet Program demostrated improvemet i HEDIS diabetes care measures, with scores that exceeded atioal averages i all measured areas. Idepedece Blue Cross (IBC) s Coectios Health Maagemet Program by providig specialized care to beeficiaries with the five most commo chroic illesses reduced ipatiet days while achievig a very high member satisfactio rate. IBC s Coectios Kidey Program resulted i 12 percet fewer emergecy room visits tha expected ad 19 percet fewer days at a skilled ursig facility tha expected i its first year. Blue Cross ad Blue Shield of Massachusetts implemeted a comprehesive disease maagemet program for members with heart failure that has show sigificat improvemet i perceived quality of life for participats. Blue Cross ad Blue Shield of Michiga provides a comprehesive spectrum of welless, disease ad symptom maagemet, as well as case maagemet opportuities for Medicare Advatage beeficiaries to take a active role i improvig their health. Blue Cross ad Blue Shield of Florida has implemeted multiple iitiatives aimed at improvig the quality of health care delivered to Medicare Advatage members, icludig disease maagemet, complex care maagemet ad populatio health iitiatives. BCBSF s HEDIS scores cosistetly exceed atioal bechmarks. Blue Cross ad Blue Shield of Miesota parters with the State of Miesota to offer a Medicare Advatage Special Needs Pla that provides a coordiated care delivery system for the most vulerable Medicare populatio: frail, elderly Miesotas with low icomes. WellPoit s Diabetes Disease Maagemet Program, which icludes case maagemet, member itervetios ad a provider pay-for-performace program, resulted i cosistet improvemet of HEDIS measures i diabetes care.

6 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Itroductio I just four years, the first of the baby boom geeratio will tur 65. I the esuig 20 years, oe i five Americas will be over age 65. These demographic chages will place eormous fiacial pressure o Medicare pressure which the curret program is ill-equipped to hadle. The Cogressioal Budget Office (CBO) estimates that federal spedig o Medicare will grow from $331 billio i 2006 to $524 billio i The icreasig icidece of chroic disease i the Medicare populatio is a critical factor leadig to this cost growth. A recet study by Ke Thorpe of Emory Uiversity traced virtually all growth i Medicare spedig from 1987 to 2002 to a 20 percet icrease i the share of Medicare patiets receivig treatmet for five or more coditios durig a year. 4 Eighty-two percet of Medicare beeficiaries have at least oe chroic coditio ad 65 percet of Medicare beeficiaries have multiple chroic coditios ad accout for 95 percet of all Medicare expeditures. 5 Some of the most costly ad prevalet chroic diseases, such as heart disease, diabetes, chroic obstructive pulmoary disease, asthma ad heart failure, are also oes where adverse evets ca be mitigated or avoided with better maagemet. Traditioal Medicare faces sigificat challeges i maagig care for those with chroic illess as a result of its curret emphasis o fee-for-service (FFS) paymets. Accordig to a report by the Istitute of Medicie (IOM), traditioal Medicare delivers care that is ofte fragmeted as patiets move amog differet physicias ad across differet care settigs, provides few disicetives for overuse of high-cost medical services ad does little to ecourage coordiated, prevetive, ad primary care that could save moey ad produce better health outcomes. 6 The curret Medicare fee-for-service paymet system is ulikely to promote quality improvemet because it teds to reward excessive use of services, high-cost, complex procedures, ad lower quality care. (Istitute of Medicie, September 2006) I its Jue 2006 report to Cogress, the Medicare Paymet Advisory Commissio (MedPAC) foud that oly two-thirds of beeficiaries received ecessary care for 20 out of 32 idicators. The MedPAC report goes o to explai that care coordiatio is more difficult to do i the FFS program because it requires maagig patiets across settigs ad over time, either of which is supported by curret paymet methods or orgaizatioal structures. 7 The strogest icetives i the Medicare program to coordiate care are through the Medicare Advatage (MA) program. Because CMS pays MA plas a capitated amout for all of the erollee s care, the pla has a icetive to esure that beeficiaries with complex eeds are well maaged across settigs ad over time. (MedPAC, Jue 2006)

7 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet For the 8.3 millio beeficiaries erolled i Medicare Advatage, a sigle etity is resposible for providig coverage of all beefits. MA plas provide traditioal Medicare beefits plus supplemetal coverage i a comprehesive pla whose reimbursemet structure ecourages a focus o prevetio ad care coordiatio, reduces fiacial barriers to care, ad creates a eviromet that fosters quality care ad satisfactio amog members. Because Medicare Advatage (MA) plas geerally have lower out-of-pocket costs tha traditioal Medicare, erollmet i MA plas could theoretically help improve beeficiaries access to care ad reduce fiacial barriers to care. With their potetial to emphasize prevetive, chroic, ad coordiated care, MA plas could beefit may miorities. (Natioal Academy of Social Isurace, October 2006) The advatages of Medicare Advatage iclude: Focus o prevetive/primary care ad coordiatio of care. MA plas place a strog emphasis o prevetive health care services that help keep beeficiaries healthy, detect diseases at a early stage, ad avoid illesses. I additio, Medicare HMOs, which still comprise the majority of MA plas, have primary care providers who are assiged resposibility for the care coordiatio of their patiets. I this way, duplicatio of services as well as risks for iadvertet adverse drug or treatmet iteractios are reduced for pla members because there is a sigle poit of resposibility for care coordiatio. A Natioal Academy of Social Isurace (NASI) report recommeds a icreased focus o care coordiatio as oe way to reduce racial ad ethic health disparities i Medicare. I its recommedatios o ways to improve quality of care, NASI recommeds ecouragig orgaized care maagemet processes icludig care coordiatio, self-care educatio for patiets, ad remiders for prevetive health visits as well as remiders to physicias at the poit of care ad ehaced commuicatio betwee providers ad patiets. 8 Chroic care improvemet/disease maagemet. While demostratio projects ad pilot programs are curretly itroducig chroic care maagemet ito traditioal Medicare, disease maagemet has log bee offered by Medicare Advatage plas. These programs seek to better coordiate health care to improve the health status of those with the most commo ad costly chroic coditios such as diabetes, heart disease, ad asthma. These programs focus o reducig health care costs ad improvig quality of life for those with chroic disease coditios over the etire course of a disease, rather tha focusig o idividual episodes of care. Reduced fiacial barriers for MA erollees. Medicare Advatage plas provide all Medicare covered beefits plus additioal beefits ot covered by traditioal Medicare. May of these extra beefits come i the form of lower cost-sharig. MA plas ted to have fixed copaymets ad most have a limit o total out-of-pocket costs. A 2005 CMS aalysis estimated that beeficiaries i MA plas save about $82 a moth or early $1,000 a year whe compared to the out-of-pocket costs for beeficiaries i traditioal Medicare.

8 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Iovatio. Sice most, if ot all, MA plas are sposored by orgaizatios that serve o-medicare members, Medicare Advatage orgaizatios ca trasfer their best practices ad prove programs developed for major employers ad other private purchasers to their Medicare programs. Health plas have much more flexibility to implemet ever-evolvig improvemets tha traditioal Medicare, due to its statutory limitatios. The profiles described i this report showcase some of the iovative ways i which Medicare Advatage plas are cotributig to improved care for Medicare beeficiaries. The profiles highlight disease maagemet programs targetig specific chroic coditios, broader populatio health iitiatives such as iflueza vacciatio ad colo cacer screeig iitiatives, pharmacy maagemet programs that target members ot takig recommeded medicatios, ad a Special Needs Pla that serves a low-icome frail elderly populatio.

9 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Blue Pla Profiles The case studies described i this report showcase a umber of iitiatives uderway at Blue Cross ad Blue Shield Plas that illustrate may of the ways i which Medicare Advatage plas are cotributig to improved care for Medicare beeficiaries. Some of these programs target patiets with specific diseases such as heart disease, diabetes, chroic obstructive pulmoary disease, asthma ad heart failure, where better maagemet ca help avoid adverse evets ad reduce costs. Others target a broad rage of chroic coditios, with particular emphasis o improvig care for those with multiple chroic coditios. These programs, which are oly a small sample of programs uderway amog Blue Cross ad Blue Shield Plas, highlight itervetios that iclude: Educatio ad support programs that provide members with educatioal materials o their coditios through telephoe calls, mailigs or videos. These programs are desiged to ehace members uderstadig of their coditios ad to help them maage their care. Health coachig iitiatives that provide access to ursig professioals to help educate members about their health coditios, ecourage positive lifestyle chages, promote self-care, ad make more iformed decisios about treatmet optios. Case maagemet programs that provide more itesive outreach to those with complex coditios to support specific itervetios ad assist i the coordiatio of care through collaboratio with members ad their health care professioals. Broad populatio health iitiatives that are desiged to improve the rates at which members receive recommeded prevetive care, such as iflueza vacciatios ad colo cacer screeig, through remiders to members ad their health professioals. Collaboratios with health professioals that iclude such activities as providig otices for member screeigs, reports regardig performace o care measures, fiacial rewards for providig high-quality care, ad educatio materials o chroic care maagemet. Pharmacy maagemet programs that ecourage members to take recommeded medicatios. A Special Needs Pla that is desiged to improve care for frail, low-icome elderly by offerig a complete rage of coordiated beefits through itegratig Medicare, Medicaid ad other programs. While some of these iitiatives are still evolvig, others have a prove track record of producig results, icludig improvemets i key measures of diabetes care, improved colorectal cacer screeig rates, reduced ipatiet admissios ad emergecy room use by patiets with cogestive heart failure ad improved osteoporosis maagemet for members who had suffered a boe fracture. Moreover, it is clear that members value these programs, as evideced by high rates of satisfactio.

10 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Cogestive Heart Failure Program Blue Shield of Califoria Blue Shield of Califoria s Cogestive Heart Failure Program coordiates persoalized care through the collaborative effort of a team of physicias ad urses usig special home moitorig equipmet. The program reduced expected ipatiet admissios ad emergecy room visits i 2005 by about 20%. Backgroud Blue Shield of Califoria offers a disease maagemet program for Medicare Advatage HMO members with cogestive heart failure (CHF). The program is desiged to maage the health of members with sigificat symptom-limitig CHF ad presetig co-morbidities. Key compoets of the program iclude coordiatio of participats medical maagemet i collaboratio with a medicatio therapy maagemet iitiative ad facilitatig timely itervetio with the participat s physicia. Target Populatio Members with CHF are further screeed for co-morbidities, icludig all medical coditios ad cogitive impairmets. A total of 499 MA members were idetified durig 2005 as potetial cadidates for this program. Further screeig of those 499 members yielded 151 qualified referrals. Key Program Elemets Cliical itervetios are supported by evidece-based guidelies ad promote a collaborative relatioship betwee physicias ad members. A idividualized, goal-orieted care maagemet pla is developed that addresses the member s CHF ad all presetig co-morbidities. This pla icludes: Desigated poit of cotact for participat Daily moitorig of symptoms through use of electroic data trasmissio from the participat s home Idetificatio ad reportig of symptoms for timely itervetio by the maagig physicia Persoalized educatio from urse case maagers Educatio for physicias ad other providers Collaboratio with physicias ad other providers Provisio of iformatio about hospice care, pai ad palliative care, ad ed-of-life care This care pla is executed via member-urse telephoe itervetio. Frequecy of urse cotacts is member ad coditio specific.

11 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Results A aalysis of 2005 data shows strog program results: Erollmet: 62.3 percet of targeted Medicare Advatage members, or 94 of the 151 qualified referrals were erolled i the program i Utilizatio: Ipatiet admissios decreased 18.9 percet from 2004 to Emergecy room utilizatio decreased 21.4 percet from 2004 to CHF Program Outcomes Medicare Utilizatio, 2004 ad Ipatiet Admits 2004 Baselie ER 2005 Outcomes Member Satisfactio: I 2005, 98 percet of members reported overall satisfactio with the program as Excellet, Very Good, or Good. I 2005, 99 percet of members respoded they would recommed the program to others. Medicatio Compliace: For members erolled i the program for loger tha six moths, medicatio compliace was strog. At year-ed 2005, the percet of these members usig a ACE ihibitor (ACEI) or a agiotesi receptor blocker (ARB) was 98 percet.

12 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Colorectal Cacer Screeig Program Highmark Blue Cross ad Blue Shield, Pesylvaia Highmark Blue Cross ad Blue Shield s Colorectal Cacer Screeig Program icreased screeig rates by over 19% from 2003 to Backgroud Colorectal cacer is the third most commo cacer amog both me ad wome i the Uited States; more tha 148,000 ew cases of colorectal cacer will be diagosed i However, colorectal cacer screeig rates are lower tha those for other commo cacers. I a effort to help Medicare Advatage members uderstad the importace of colorectal cacer screeig, Highmark BCBS focuses ogoig efforts o itervetios that have improved colorectal cacer screeig rates. Target Populatio All Medicare Advatage members betwee the ages of 65 ad 80. Key Program Elemets Educatio ad support. Through its coditio maagemet program, Highmark distributes to its members a videotape developed by the Foudatio for Iformed Medical Decisio Makig. The video is desiged for people age 50 to 80, who are at average risk for colo cacer, to help decide whether to have screeig, ad which type of screeig to choose. Highmark also distributed free DVDs from the America Cacer Society to provider offices for viewig i waitig rooms. The DVDs explai available screeig optios to seiors. Highmark published educatioal articles o colorectal cacer screeig i member ewsletters to icrease their uderstadig of the importace of colorectal cacer screeig. Telephoe outreach. I the sprig of 2006, a Iteractive Voice Recogitio educatioal telephoe outreach campaig was delivered to approximately 72,115 Medicare members, iformig them of the importace of colorectal cacer screeig ad types of screeig, as well as solicitig feedback o barriers to receivig screeig. Collaboratio with health care providers. Highmark has bee workig closely with primary care physicias to idetify ways to improve colorectal cacer screeig, icludig idetifyig best practices ad sharig office protocol. Highmark also published educatioal articles o colorectal cacer screeig i physicia ewsletters, ad provided liks to free cotiuig medical educatio. Aual publicatio of Prevetive Health Guidelies o the Highmark provider resource ceter website keeps Highmark providers up to date with the atioal stadards ad recommedatios. 10

13 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Results The colorectal cacer screeig measure estimates the percetage of adults years of age who have had appropriate screeig for colorectal cacer. Sice 2003, Highmark s HEDIS rates for its Medicare members for colorectal cacer screeig have demostrated substatial improvemet. I 2005, the most recet measuremet year, Highmark s rates for colorectal cacer screeig for its Medicare Advatage populatio were above the atioal average as determied by the Natioal Committee for Quality Assurace. Highmark HEDIS Medicare HMO Rates 2003 Measuremet Year 2004 Measuremet Year 2005 Measuremet Year 2005 Natioal Average 50.12% 55.75% 59.85% 53.90% 11

14 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Improvig Outcomes for Medicare Members with Diabetes Highmark Blue Cross ad Blue Shield, Pesylvaia Highmark Blue Cross ad Blue Shield improved outcomes for members with diabetes by implemetig a diabetes care maagemet program that itegrated outreach ad educatio, health coachig, ad collaboratio with health professioals. Highmark s rates for all measuremets for its Medicare diabetic populatio were above atioal averages established by the Natioal Committee for Quality Assurace. Backgroud I a effort to help Medicare Advatage members with diabetes better cotrol their coditio ad avoid complicatios, Highmark has focused o member ad practitioer itervetios that have improved the rate of diabetes-related screeigs. Target Populatio Curretly, there are early 50,000 Medicare Advatage members idetified as havig a diagosis of diabetes who are eligible for this program. Key Program Elemets Member educatio. Members ewly idetified with diabetes ad diabetics with gaps i testig receive mailigs that iclude periodic member ewsletters cotaiig up to date iformatio o diabetes ad persoal utritio couselig. Telephoe cotacts ad health coachig. Program participats receive support via iboud ad outboud access to traied health coaches 24 hours a day, 7 days a week. I 2006, Iteractive Voice Recogitio educatioal telephoe outreach was added. Collaboratio with health care providers. Highmark seds biaual reports to members primary care physicias to alert them about critical screeigs for their patiets with diabetes. The reports also idicate co-morbid coditios that could impact these patiets. Additioal support to health care providers icludes: Aual adoptio ad dissemiatio of cliical practice guidelies for diabetes Ogoig educatio via physicia ewsletters ad free cotiuig medical educatio Provider resources available olie ad via CD A Pay for Performace Quality Icetive Program that offers a fiacial reward for providig efficiet, high-quality health care that icludes quality idicators for diabetes 12

15 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Results Sice 2000, Highmark s HEDIS rates for its Medicare HMO members with diabetes have demostrated improvemet i all measured areas, icludig blood glucose (A1C) testig ad cotrol, LDL cholesterol testig ad cotrol, diabetic retial exams, ad moitorig for ephropathy. I 2005, the most recet measuremet year, the Comprehesive Diabetes HEDIS Measure icluded 21,855 eligible Medicare Advatage HMO members usig Natioal Committee for Quality Assurace (NCQA) criteria. Highmark s rates for all measuremets for its Medicare diabetic populatio were above the atioal average as determied by NCQA. Highmark Medicare HMO HEDIS Rates Comprehesive Diabetes Care Measuremet Years 120% Natioal Average 100% 91.97% 96.59% A1C Testig % 84.43% 70.32% 91.73% 77.86% 74.94% LDL Test Diabetic Retial Exam 60% 40% 50.85% 39.66% 40.39% 65.69% 55.96% LDL Cotrol <130 mg/dl Moitorig for Nephropathy 20% 0% % 16.06% LDL Cotrol <100 mg/dl A1C Poorly Cotrolled >9% 13

16 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Improvig Osteoporosis Maagemet Highmark Blue Cross ad Blue Shield, Pesylvaia Highmark Blue Cross ad Blue Shield s Osteoporosis Maagemet Program demostrated a 9% icrease i members receivig maagemet services after a boe fracture from 2003 to 2005 through ehacig outreach ad collaboratio with physicias. Backgroud I a effort to help Medicare Advatage members uderstad osteoporosis ad their previous fractures as a risk-factor for potetial future fractures, Highmark has focused o member ad practitioer itervetios that have improved the rates of osteoporosis maagemet post fracture. Target Populatio Female members age 65 ad older who had suffered a fracture durig the measuremet year (excludig fractures of figers, toes, faces, or skulls). Key Program Elemets Mailigs ad icetives. I 2005, Highmark set 1,165 letters to female members age 65 ad older who had a fracture. The purpose of the letter was to educate these members about osteoporosis ad its prevetio ad to ecourage these wome to discuss boe mieral desity testig ad medicatios with their health care providers. A icetive, i the form of a pill box, was offered to those members who took the letter to their provider ad had it siged. I additio, iformatio about the Highmark Osteoporosis Prevetio ad Educatio (HOPE) program was detailed i member ewsletters. Telephoe outreach. I the fall of 2005, a Iteractive Voice Recogitio educatioal telephoe outreach campaig was delivered to 1,563 Medicare members who were idetified as havig had a fracture. Collaboratio with health care providers. Highmark published educatioal articles o osteoporosis i physicia ewsletters, provided liks to free cotiuig medical educatio programs ad set letters to physicias treatig wome who had suffered fractures, remidig them to order boe mieral desity testig ad to cosider medicatios to treat or prevet osteoporosis i these members. Results From the time that Highmark first bega to aalyze data for osteoporosis maagemet post fracture i 2003, Highmark s rates o osteoporosis maagemet have improved from percet to percet i The 2005 rate far exceeds the atioal average of 20.1percet established by Natioal Committee for Quality Assurace. 14

17 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Measure 2003 Measurmet Year Highmark HEDIS Medicare HMO Rates 2004 Measurmet Year 2005 Measurmet Year 2005 Natioal Average Osteoporosis Maagemet Post Fracture 38.85% 40.34% 42.32% 20.1% 15

18 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Coectios sm Idepedece Blue Cross, Pesylvaia Idepedece Blue Cross (IBC) s Coectios Health Maagemet Program by providig specialized care to beeficiaries with the 5 most commo chroic illesses reduced expected ipatiet days while achievig very high member satisfactio rates. IBC s Coectios Kidey Program resulted i 12% fewer ER visits tha expected ad 19% fewer days at a skilled ursig facility tha expected. Backgroud Idepedece Blue Cross (IBC) lauched the Coectios SM Health Maagemet Program i The program focuses o the five most commo chroic diseases: asthma, diabetes, chroic obstructive pulmoary disease (COPD), heart failure, ad coroary artery disease. It also provides decisio support services to members facig sigificat medical decisios. IBC expaded this program i 2004 with a program to support members with chroic kidey failure. I 2005, IBC added a program for idividuals with ay of 15 complex chroic coditios, ad expaded this to a 16th coditio i late Coectios Health Maagemet Program Target Populatio Program participats are idetified ad stratified ito risk groups. Health care practitioers ad case maagers may also refer members to the program, ad idividuals ca self-refer. Sice its iceptio i 2003, early 85,000 Medicare Advatage HMO ad PPO members have bee idetified as eligible for the program (i.e., as havig oe of the five targeted coditios). Key Program Elemets Mailigs ad remiders. All participats idetified with oe or more of the five chroic coditios receive mailigs with coditio-specific iformatio, alog with remiders to schedule recommeded treatmets ad procedures Ogoig health coachig. Members have 24/7 access to health coaches who are registered urses, dieticias, or respiratory therapists. Members stratified as high risk receive phoe calls from coaches. They help members uderstad ad follow physicias treatmet plas; ad o average, cotact members 5-7 times per year. Ehaced decisio support. Members ca speak with health coaches to discuss treatmet optios for a variety of medical coditios, icludig back pai, cacer, weight loss surgery, ad wome s ad me s health issues. Results I 2006, IBC s Coectios Programs were awarded the Disease Maagemet Leadership Award for Outstadig Health Pla from the Disease Maagemet Associatio of America. A 2005 survey of all IBC members foud 87 percet of members satisfied or very satisfied with health coaches services; 90 percet said they would recommed the program to others. 16

19 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Year 1 program results idicated that there was a 1.5 to 2 percet reductio i medical cost tred across all eligible IBC members. For Medicare Advatage members, Year 2 results idicated savigs i medical cost tred ragig from 3-5 percet. For both years measured, ipatiet days for MA members were 9-14 percet less tha expected ad professioal services for these members were percet less tha expected. Coectios Kidey Program Target populatio This program targets members with ed-stage real disease (ESRD) who are receivig dialysis. There are curretly 351 Medicare members with ESRD i the program. Key Program Elemets Cotacts ad assessmets. Iitial cotact from program erollmet staff is followed by cotact from experieced dialysis urses, who coduct cliical assessmets ad meet with participats at their dialysis sites or at home. Care coordiatio. Based o these assessmets, the coordiators work with the dialysis care teams to provide care ad support for all patiet eeds related to ESRD ad other health coditios. Reportig. Patiet-level ad practice-level data o outcomes are reported o a quarterly basis to participats primary care physicias, kidey specialists, ad dialysis ceter staff. Results Year 1 program results idicate savigs of 5 percet off medical cost tred for ESRD Medicare members. Ipatiet days were 3 percet below expected, skilled ursig facility days were 19 percet below expected, ad emergecy room visits were 12 percet below expected. Coectios AccordatCare Target populatio This program targets idividuals with ay of 16 complex chroic coditios (e.g., multiple sclerosis, Parkiso s disease, rheumatoid arthritis). As of September 30, 2006, 3,349 Medicare members participated i this program. Key Program Elemets Telephoe cotact with urse disease maagers. Idetified members receive calls from disease maagemet urses who assess the members eeds ad work to help them follow physicias treatmet plas so they ca avoid potetial health/medical complicatios. Iformatio. Program participats receive mothly ewsletters with iformatio about their coditios, ad they ca access coditio-specific iformatio o Accordat s Web site. Result: Year 1 outcome results are curretly beig aalyzed. 17

20 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Blue Care Coectio for Heart Failure Blue Cross ad Blue Shield of Massachusetts Blue Cross ad Blue Shield of Massachusetts implemeted a comprehesive disease maagemet program for members with heart failure that has show improvemet o both cliical measures ad perceived quality of life for participats. The Blue Care Coectio for Heart Failure, a comprehesive populatio-based disease maagemet program for members with heart failure, was implemeted i 2001 to improve the support ad care to members with heart failure (HF) ad their treatig physicias. The program focuses o closig gaps i care (e.g., use of ace ihibitors) ad empowerig members to remai egaged i their care maagemet. Target Populatio The program icludes more tha 1,700 Medicare Advatage HMO ad PPO members diagosed with cogestive heart failure as of Jauary 31, Key Program Elemets Outreach ad educatio. Nurses traied i the area of cardiac disease work with treatig physicias to support their treatmet plas through outreach, educatio ad surveillace. Participats also receive welcome kits with a disease-specific workbook ad other educatioal iformatio. Participats receive calls at least every six weeks, ad sometimes as frequetly as daily or more as idicated by assessed eeds. Iitial assessmet ad follow-up. Followig a idividual assessmet, participats receive assistace with self-maagemet of their disease through educatio regardig medicatio maagemet, adherece to diet ad exercise plas, ad coordiatio of physicia-ordered services. Additioal member itervetios iclude: idividualized self care goals, Stadards of Care remiders reports, quarterly cardiac disease-specific ewsletters, ad home moitorig for members who require additioal support. Home moitorig icludes a electroic scale, blood pressure ad pulse devices with results trasmitted to disease maagers daily. Physicia ivolvemet. Physicias receive feedback about their patiets status (icludig data from home moitorig, if applicable) alog with regular updates o cliical guidelies that support evidece-based treatmet of heart failure. Registered urses also make visits to physicia offices to provide physicias with program specific iformatio ad tools such as flu vaccie remiders ad patiet rosters. A Physicia Advisory Coucil (PAC), icludig providers i the BCBSMA etwork, provides cliical iput ad oversight. Results Cliical measures. BCBS MA s Blue Care Coectio for Heart Failure program has maitaied the gais attaied sice the program s iceptio. While there are umerical chages i the rate, oe showed ay statistically sigificat differeces. 18

21 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Percet of Medicare Advatage HMO members with heart failure cliical measures Year 1 Year 2 Year 3 Year 4 Documeted EF LVSD o ACEI ** EF or ejectio fractio is a measuremet of how well the heart is pumpig. LVSD o ACEI is a measure used to assess the percet of heart failure patiets with left vetricular systolic dysfuctio (LVSD) ad without both agiotesi covertig ezyme ihibitor (ACEI) ad agiotesi receptor blocker (ARB) cotraidicatios who are prescribed a ACEI or ARB at hospital discharge. The data reported here iclude those with documeted cotraidicatios to ACEI therapy. ** While the proportio of members prescribed a ACEI for LVSD fell 7.3 percet i Year 4, the chage is ot statistically sigificat due to the small sample size. (A sample of medical records is reviewed.) Whe ARB use is factored i, the rate of ACE/ARB use is 95 percet. ARB is accepted as appropriate first-lie therapy for LVSD patiets. Member satisfactio for the Heart Failure Program is measured at 95 percet. Member quality of life. Members perceptios of their fuctioal status are measured usig the Miesota Livig with Heart Failure Questioaire, a recogized istrumet for assessig quality of life for patiets with heart failure, with questios assessig both physical ad emotioal well-beig. Scores that declie from the baselie measuremet idicate improvemet i perceived fuctioal status thus, the results below show a sigificat improvemet i perceived quality of life resultig from the Heart Failure program. Follow-up periods are geerally oe year i legth. Patiet Perceptios Baselie Follow up 1 Follow up 2 Follow up 3 Total Score *Physical *Emotioal * Note: Heart Failure is a progressive coditio ad despite perceived decrease i physical scores i the third follow-up period, scores did ot revert to baselie or higher ad gais i the emotioal compoet were maitaied. 19

22 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Iitiatives to Improve the Health of Medicare Advatage Beeficiaries Blue Cross ad Blue Shield of Michiga Blue Cross ad Blue Shield of Michiga provides a comprehesive spectrum of welless, disease ad symptom maagemet, ad case maagemet opportuities for Medicare Advatage beeficiaries to take a active role i improvig their health. Blue Cross Blue Shield of Michiga (BCBSM) is presetly offerig or is i the process of fializig several iitiatives geared towards improvig the health of its Medicare Advatage (MA) members through its itegrated care maagemet program, BlueHealthCoectio. BlueHealthCoectio Backgroud BlueHealthCoectio provides a comprehesive spectrum of welless, disease ad symptom maagemet, ad case maagemet opportuities for Private Fee-for-Service (PFFS) Medicare Advatage beeficiaries to take a active role i improvig their health. Program elemets are delivered through two parters with sigificat experiece i iteractig with Medicare populatios. Both have had sigificat success i uderstadig the illess burde of Medicare beeficiaries ad proactively idetifyig, through state of the art predictive modelig techiques, who is at risk for high cost, what diseases are preset i this populatio, ad whether the health of the populatio is improvig or whether further itervetio is ecessary. Key Program Elemets Health coachig. Health coaches provide proactive outreach ad iteractio with a persoal health care coach to address a full rage of health care decisio eeds, icludig maagemet of chroic coditios (asthma, diabetes, coroary artery disease, cogestive heart failure, ad chroic obstructive pulmoary disorder) as well as preferece sesitive coditios, such as cacer, beig uterie coditios, ad back pai. The program is focused o buildig selfreliace, ad seeks to iform members by providig balaced iformatio, trasferrig skills ad cofidece, ad eablig members to take actio. Program iitiatives iclude: Iboud phoe calls to a 24/7 toll-free urse call lie, as well as outboud calls ad mailigs to idetified at-risk beeficiaries A whole perso care maagemet approach that icludes healthy livig support, urget eeds support, coditio maagemet ad complex care support A coachig process that dissemiates iformatio, teaches self-reliace ad self-care skills, supports the provider relatioship ad provides a opportuity for members to discuss values ad prefereces ad their readiess to chage As a result of the coachig itervetio, participats (ad/or their care givers) are well iformed about their coditios, uderstad ad follow their treatmet plas, ad kow what to do whe their plas are ot workig. They are more cofidet of their ability to avigate the health care system ad get the help they eed, ad actively participate i makig health care decisios with their doctors, relyig o evidece ad hoorig their ow values. 20

23 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Case maagemet. A case maagemet program focuses o high-cost members/those impacted by multiple co-morbidities (typically 3-5 percet of the populatio), ad its complex case maagemet focuses o the highest-cost members/those with the most complex care requiremets (1-2 percet of the populatio). Case ad complex case maagemet are collaborative processes that assess, pla, implemet, moitor ad evaluate optios ad services to meet a idividual s health care eeds ad assist patiets i uderstadig ad participatig i their health care plaig. These iitiatives provide telephoic ad face-to-face assessmets, develop collaborative care plas with physicias ad beeficiaries, ad use evidece-based guidelies to measure compliace ad treatmet success. Itervetios iclude: Regular iteractios with member, physicia ad family members to moitor health status, progress ad compliace Telemoitorig devices Ogoig cliical ad psychosocial eeds assessmets 21

24 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Seior Care Solutios Blue Cross ad Blue Shield of Florida Blue Cross ad Blue Shield of Florida has implemeted disease maagemet, complex care maagemet ad populatio health iitiatives to improve the quality of health care for Medicare Advatage members. BCBSF s HEDIS scores cosistetly exceed atioal bechmarks. Backgroud Blue Cross ad Blue Shield of Florida s Seior Care Solutios iclude multiple iitiatives aimed at improvig the quality of health ad health care delivered to its Medicare Advatage members. Three program areas are highlighted here: disease maagemet; complex care maagemet; ad populatio health maagemet programs. Disease Maagemet Programs Curret disease maagemet programs iclude those that focus o diabetes, heart failure ad asthma. These programs adhere to NCQA ad HEDIS guidelies with scheduled performace measures to idetify effectiveess ad opportuities for future programs. Expasio of programs for the coditios of coroary artery disease ad chroic obstructive pulmoary disease are aticipated i Key Program Elemets Idetificatio of members with targeted coditios Health risk assessmets for fuctioal, cogitive ad safety evaluatios Educatioal iformatio Member ad/or caregiver health coachig Telephoe cotact with follow-up. Members ad/or caregivers ca make iboud phoe calls for symptoms, evet-drive questios or referrals. They are provided resources ad educatio o the importace of adherig to physicias treatmet guidelies ad educatioal support to achieve ad maitai optimal health coditios Collaboratio betwee primary care providers ad specialists idetifies opportuities to arrow cliical gaps Care Maagemet Programs Complex care maagemet programs focus o the top 2 percet of Medicare Advatage members who cotribute to the top 15 percet of medical costs. These programs provide focused ad idividualized approaches to assist members with achievig health care goals that are cosistet with their culture ad beliefs while also miimizig their out-of-pocket expeses. Expasio of these programs to iclude promotio of peumoia vacciatio, palliative care, chroic kidey ad stroke is aticipated i Key Program Elemets Persoal cotact with members/caregivers to promote adherece to medicatios Self-maagemet ad iformed participatio i health care decisios A dedicated poit of cotact for eligibility, beefits ad available programs Ehaced provider egagemet Idetificatio of commuity resources Promotio of evidece-based medicie

25 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet The expasio of the CMS-required Health Risk Assessmet for early idetificatio of barriers to health care access, persoal ad evirometal safety ad/or adherece to physicia treatmet plas are aother compoet of these programs. Populatio-Based Prevetive Care Iitiatives Populatio-based care iitiatives ecourage prevetive immuizatios ad screeig to promote quality of care, quality of life ad to decrease medical costs. Immuizatio ad screeig schedules for the seior populatio are recommeded by atioal orgaizatios. These programs iclude iflueza/peumoia vacciatio campaigs ad idetificatio ad educatio of members for colorectal cacer screeig. Key Iitiatives Iflueza/peumoia vacciatio campaig. Natioal orgaizatios recommed aual iflueza vacciatio ad a peumoia vacciatio every five years for people over 65 years of age. BCBSF parters with a vedor to provide aual flu-cliics that are admiistered throughout Florida to its seior members. These cliics are advertised via ews releases ad radio. Colorectal cacer screeig. BCBSF has collaborated with the America Cacer Society (ACS) ad health departmets to ecourage colorectal cacer screeig for idetified seior members who do ot have evidece of previous screeig i claims data. These members are mailed letters that iclude ACS brochures idicatig the importace of colorectal cacer screeigs ad follow-up with their physicias. The BCBS Florida Web site also provides a direct lik to the ACS website ad iformatioal remiders for appropriate screeig. Provider educatio icludes Cotiuig Medical Educatio credit from the ACS ad iformatio i provider ewsletters. Subsequet iitiatives will cotiue to iform members of the beefits of screeig. Additioal efforts may iclude follow-up with specific members as well as their primary care provider, ocologist ad other specialists. Results Recetly developed seior programs for a curret populatio of 21,000 Medicare Advatage members iclude moitorig of program results with cotiuous quality improvemet. Historically, BCBSF s HEDIS scores for Medicare HMO members have cosistetly exceeded Natioal Committee for Quality Assurace (NCQA) atioal bechmarks for the followig idicators: HEDIS Measure Nat l Avg Diabetes - HbA1C Test 88.10% 97.57% 89.10% Diabetes - Lipids Test 95.90% 98.05% 93.50% Diabetes - Lipids Cotrolled < % 77.62% 71.40% Diabetes - Nephropathy Exam 42.30% 73.24% 58.60% Cotrollig High Blood Pressure 74.90% 67.43% 64.70% Beta Blocker After Heart Attack 89.90% 96.00% 94.00% Colorectal Cacer Screeig NR 52.72% 52.60% 23

26 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet SecureBlue a Medicare Advatage Special Needs Pla Blue Cross ad Blue Shield of Miesota Blue Cross ad Blue Shield of Miesota parters with the State of Miesota to offer a Medicare Advatage Special Needs Pla that provides a coordiated care delivery system for the most vulerable Medicare populatio: frail, elderly Miesotas with low icomes. Backgroud Medicare Advatage special eeds plas (SNPs) are a ew type of coordiated care pla established by the 2003 Medicare Moderizatio Act. Created to ecourage more opportuities for special eeds idividuals to access maaged care, the SNP optio allows Medicare Advatage plas to specialize i care for beeficiaries who are residig i log-term care facilities, dually eligible for Medicare ad Medicaid, or chroically ill. With the SNP desigatio, plas may limit erollmet to oe of the special eeds populatios, tailorig beefits ad provider etworks to best meet the eeds of these vulerable groups. Origially lauched o a limited scale i 1997 for the Mieapolis-St. Paul area, Miesota Seior Health Optios (SHO) is a Medicare Advatage SNP that is admiistered by multiple health plas, icludig Blue Cross Blue Shield of Miesota, which offers SecureBlue as its SHO program through its HMO affiliate, Blue Plus. The pla combies Medicare ad Medicaid beefits ad commuity services ito a seamless program for idividuals who qualify. By desig, SHO cosolidates all paymet sources for Medicare ad Medicaid to elimiate paperwork ad cofusio for eligible members, their providers ad their families. The program also coordiates ursig home, assisted livig, home health, commuity services, case maagemet, equipmet services ad other service programs that may be uique to each couty. Each erollee gets a iitial health ad eeds assessmet, ad the seamless coordiatio ad provisio of services they eed to ejoy their best health. Target Populatio The program serves more tha 35,000 of the state s most vulerable Medicare populatio: frail, elderly Miesotas with low icomes. These idividuals live at home ad i istitutioal settigs, ad are scattered throughout the state both i metropolita Mieapolis-St. Paul ad the largely rural commuities of greater Miesota. SecureBlue serves early oe-third of all SHO members (10,000 erollees) i 58 of Miesota s 87 couties. Key Program Elemets Providig care ad services closer to home. Because of its history of successful collaboratio with couty agecies, SecureBlue cotracts with couties to provide local care coordiatio services to may of its members who are erolled i SHO. This cotractig arragemet brigs care ad commuity support closer to home for Medicare ad Medicaid members across the state, which is especially importat i the rural areas of Miesota, where the populatio overall is agig. The Blues were istrumetal i leadig the charge i developig relatioships with couties for home based services, especially i rural areas, so we ca capitalize o existig capabilities ad brig erollees ito a care maagemet situatio where more attetio ca be paid to chroic health coditios. 24 Pam Parker, maager of special eeds purchasig for the State of Miesota.

27 Medicare Advatage: Improvig Care Through Prevetio, Coordiatio ad Maagemet Offerig persoalized care coordiatio. As a hallmark of the program, each SecureBlue member is assiged a care coordiator to assist with questios, commuity service referrals, iteractio with providers ad isurace compaies, ad ay other care-related cocers. The care coordiators are professioal urses or social workers. The uique coordiatio possible uder this Medicare Advatage SNP allows for a itegrated care delivery system that creates greater efficiecies for everyoe ivolved, especially members, their families ad their providers. Care coordiators have direct cotact with the seiors ad, i may ways, are i the best positio to assess how they are really doig at home. What may people do t realize is that seiors have more tha just medical care ad related service eeds. There might be metal health issues, chemical health cocers, fiacial barriers, ad formal ad iformal support issues to cosider. By stayig i close cotact, the care coordiator ca lear about these issues ad help members fid resources to meet their specific eed. Jodi Wetlad, social services supervisor for Otter Tail Couty Huma Services Itegrated whole-perso care. Itegrated services iclude health care, trasportatio, Meals O Wheels, home visits, alterative livig ad accessibility services, additioal safety features such as drug dispesers, telemedicie especially importat i rural areas ad other iovative approaches to care i the home. Best of all, workig with local couty agecies meas that the couties are already familiar with the care ad eeds of these erollees. Results Although the SNP program is too ew to have reported ay results, Violet s story shows how the program s itegrated approach ca beefit Medicare Advatage members. Violet s Story Early i 2006, Violet*, a 70 year-old SecureBlue member, was discharged from the hospital with a tube iserted i her trachea, so a vetilator could help her breathe. She was authorized for a short-term stay at a skilled ursig facility, ad there were cocers whether she would ever be healthy eough to retur home. Violet s sister her oly livig relative resided at the same facility ad provided compaioship. But Violet eeded more. She eeded aggressive, professioal care coordiatio, ad her SecureBlue care coordiator became her lifelie. She maitaied close cotact with the facility about Violet s coditio. At first, Violet worseed. She eeded the vetilator ightly ad all expected that her short-term stay would become permaet log-term care. Whe her sister died, Violet decided it was time for her to leave the facility, as well. She wated to go home. By the her coditio had improved ad she o loger eeded the vetilator, but she did eed a extra had at home ad someoe to look out for her. Violet s SecureBlue care coordiator made it all possible. She worked with the skilled ursig facility o Violet s discharge plaig, arraged skilled ursig ad home health aide visits, a Lifelie phoe uit, ad a wheelchair accessible ramp for her home. Almost three moths after Violet etered the skilled ursig facility, she was livig i her ow home agai, maagig her health ad cofidet that her SecureBlue care coordiator would help her weather ay health situatio to come. *The member s ame has bee chaged. 25