Life Sciences

Medicare & Reimbursement Advisor Weekly, June 3rd, 2009

Medicare & Reimbursement Advisor Weekly, June 3, 2009


Copay assistance, patient balances up in downturn, but long-term payer contracts are greater concern

NAMs-RAMs-CAMs: Are you engaging plans that have taken DM in-house?

Copay assistance, patient balances up in downturn, but long-term payer contracts are greater concern

Although there haven’t been significant average sales price/average wholesale price reimbursement changes for specialty providers such as oncology practices, there’s concern on the horizon. Many practices lock in payer contracts for multiple years. Mid Ohio Onc/Hem in Columbus locked in contracts in January for three years in some cases, and the reimbursement is based on 2008 Medicare rates. “If rates go down, it will be harder for us to go back and negotiate better rates. And even if they don’t go down, what if inflation goes up? We could face a more challenging business setting than what’s going on today, making payroll harder to meet, for example, bringing in access issues,” says Glenn Balasky, executive director at Mid Ohio Onc/Hem. The economic downturn has lowered volume about 5% and increased patient balances by 20%, compared to this time in 2008, forcing the group to reduce staff time on Fridays and shop for lower drug prices—even 20-cent savings on generic support agents, says Balasky. Pharmaceutical assistance is tracking at about $70,000 per month, up 40% from the same time last year. Judy Stone, director at Carolinas Hem/Onc, says free drug assistance has tripled in the first half of the year due to flattening volume, higher deductibles, and odd plan policies that only cover inpatient chemo treatment. Stone is concerned that patients will present to the group more sick, “at a higher-stage cancer.”

NAMs-RAMs-CAMs: Are you engaging plans that have taken DM in-house?

How BCBS of MN, Horizon created in-sourced health management models

Editor’s note: Many plans, as discussed in the “How far to push, how much to pull” article (MRAW, May 27) are looking for better ways to do disease management (DM). Some employ passive programs to give members literature about conditions, whereas others are more interactive. Can your company fill gaps? Some account teams have developed a strategy to have a dual NAM or RAM tag-team approach with two account people focused on an account: one with contracting expertise, the other focused more on pull through and DM. There are also other models. In the following article, we look at two Blue Cross customers and the trend of moving DM in-house. As the trend heightens, it will be important to understand what challenges plans encounter and what new opportunities emerge for pharmaceutical companies to support plan objectives.

Displeased with the money they’re paying to DM vendors and dissatisfied with DM’s results, more health plans are moving those services in-house.

A pair of Minnesota health plans did it in 2008—Blue Cross Blue Shield of Minnesota (featured) and Medica. To gain more control over the health of its members, Blue Cross Blue Shield of Minnesota severed ties with Healthways and began offering most of its DM services in-house in January 2009.

David Plocher, MD, chief medical officer and senior vice president of health management and informatics at Blue Cross Blue Shield of Minnesota in St. Paul, says outsourced DM vendors simply do not have the relationships with providers that health plans enjoy. “We have a responsibility to help our members improve their health status as much as we can, and an outsourced company doesn’t have our linkages to providers, and so when we want to collaborate with providers, we need to be in charge of the health management programs,” Plocher says.

Blue Cross’ new offerings are not a “me-too approach,” but one in which new features can potentially help all members, not just those with chronic diseases, he says. Blue Cross Blue Shield of Minnesota will offer Whole Person Health Support, a health management program that goes beyond traditional DM. The health plan says Whole Person Health Support is more expansive than DM in the areas of identification and stratification, consent and engagement, and integration.

“We use entirely different methods to find people. We want to concentrate on finding people who really need to be found and whose course we can modify and who are ready to change behavior,” Plocher says.

The health plan is also using advanced claim pattern software that filters claims to find gaps in care, such as failures in medication refills and testing; reviews referrals; biometric screening; hospital discharges; and health risk assessments.

The switch to in-sourcing will allow the health plan to revamp the health management programs rather than negotiating changes with a vendor. “The owner, the health plan, always wants control, flexibility, and speed. That’s easier to manage when it’s an in–house-owned program,” Plocher says.

Blue Cross hopes to gradually in-source additional programs. Two programs that will remain outsourced for now are an online health assessment and a nurse triage line. Blue Cross also believes that in-sourcing more DM services will allow them to offer Whole Person Health Support at a lower price than the traditional DM program, says Plocher.

Blue Cross will hire 80100 employees to handle the DM services, a majority of whom will staff a nurse call center. Plocher notes that the health plan is investing in technology for the call center and decision health platform.

At one point, Blue Cross had more than 250,000 members enrolled in a variety of DM programs. This gave Plocher and his team knowledge about what does and does not work with DM models. In addition, Blue Cross built and operated its own heart failure program for Medicare members, which was recognized by CMS as a highly successful model.

This experience gave Blue Cross the know-how and foundation to create the “next generation” of health management programs it is bringing to the market, Plocher says.

Blue Cross educated members about the program changes through outreach and on-site tours. “It’s a large communication effort to re-orient our purchasers, because this really does change the game from the old days of marketing one disease program at a time,” he says.

Bringing the DM services in-house and providing a larger health management program will help Blue Cross members. “It’s easier for us to deliver Whole Person Health Support with our in-sourced programs, because we don’t have handoffs, we don’t have data being sent to outsourced companies. It’s fully integrated,” says Plocher.

Horizon slowly brought DM in-house

In-sourcing DM programs is not new to Horizon Blue Cross Blue Shield of New Jersey, which began moving those services in-house in 2003.

The first internal DM program it launched focused on asthma and chronic obstructive pulmonary disease. Over the past five years, Horizon has added DM programs with telephonic health nurses for patients with chronic kidney disease, diabetes, Hepatitis C, Multiple Sclerosis, heart failure, and patients with weight management problems. Horizon also offers a mail-only program to hypertension patients.

Premila Kumar, MD, PAHM, manager of care management at Horizon Blue Cross Blue Shield of New Jersey in Newark, was the third person hired by Horizon when it began bringing DM services in-house. Horizon’s DM unit now has a staff of more than 100 employees, who serve about 185,000 members in DM programs.

The costs were not the only reason the health plan brought the DM services in-house. “I don’t think there are any drawbacks in administering programs in-house. I think we have a better control of them,” says Kumar, adding that in-sourcing DM services allows Horizon to more effectively control its products and members, and provides integration between DM, case management, and inpatient case management.

Developing a program from scratch takes not only employees, but also technology integration. As time progressed and programs were added, the health plan found that the internal DM computer system could not communicate with other parts of Horizon’s services. Horizon transitioned in 2008 to put all DM services, including care specialists, case managers, and utilization management nurses, on the same computer platform, Kumar says. This allows Horizon to offer a better coordination of care.

Al Lewis, executive director of Disease Management Purchasing Consortium International, Inc., in Wellesley, MA, has a different take on technology. “Technology goes the other way, because vendors can get technology and spread it out over many more people than in-sourced programs can,” Lewis says.

Finding those at risk

Horizon finds at-risk members through claims data, including medical, pharmacy, and laboratory; and a health risk assessment. Instead of contacting at-risk members months after discharge, a health plan should have that information in a few days or weeks. Receiving claims data sooner and, in turn, contacting members faster, is an area in which health plans could gain an advantage over vendors, Lewis says, but he adds that health plans have not been able to receive prompt claims information.

Another advantage for health plans is their connection to physicians. Horizon nurses communicate with member physicians when there is a concern with a patient and they request specific clinical information. Physicians have been receptive to the interaction. The health plan also reaches out to physicians via newsletters and seminars, including ones that target physicians with a high number of diabetes patients, says Kumar.

By bringing DM services in-house, Horizon has learned the challenge of getting members on the phone, she says. Rather than having clinical nurses make those calls, Horizon hired nonclinical people to make the initial calls. Once the laypeople get a member on the phone, they engage the members and transfer them to a nurse after a few questions. This service frees up nurses to perform tasks other than calling members who are not at home.

Horizon bringing the programs in-house is a benefit to members, Kumar says, adding, “I wouldn’t say anything is hard to duplicate [for health plans]. On the contrary, I think vendors will have a tough time duplicating what we do.”

Note: This article is from Population Health Insider, an MRAW sister publication for health plans, published by HealthLeaders.