Faced with the reality that only 10 percent of all patients drive at least 60 percent of all healthcare costs, Health Care Service Corporation (HCSC) and its Blues plans have taken action to lower costs while better addressing these patients' needs. Enter the fourth largest insurer's new medical home model--the intensive outpatient care program.
Working with one of its largest employer accounts, Boeing, HCSC launched this unique medical home, which employs HCSC-funded nurse care managers to help this small but pivotal group of healthcare consumers who suffer from complex and chronic conditions that often dovetail with other complicated social and behavioral issues like depression, anxiety and substance abuse. The care managers offer medical and psychosocial support while coordinating and monitoring patients' progress during office visits and frequent communication.
To learn more about this new medical home initiative, FierceHealthPayer spoke with Scott Sarran (pictured), chief medical officer, HCSC government programs.
FierceHealthPayer: Can you describe how HCSC's intensive medical home program works?
Scott Sarran: We're already doing several things within the broadly defined accountable care space, but we're very strong believers in is the intensive medical home. That program, in essence, is built around identifying what we call persistently and actionably high-risk, high-cost members.
And then we fund a nurse care manager who is employed and housed within a physician group practice. That care manager is charged with the accountability, in conjunction with the physician, for developing a shared individualized care plan and following that care plan through to execution with the member and physician over time.
FHP: What drove HCSC to create this program?
Sarran: It was a sense that we've got a lot of other programs in place already that are pretty effective at dealing with the less high-risk members. The internal disease management program and the more broadly based medical homes both have a fairly significant impact on the mainstream population of people with chronic diseases. So we feel like we've been able to move the needle on those topics.
But we've seen a persistent, relatively small percent--maybe 10 percent of members in a commercial population--who are really challenging and who, despite our existing programs, need more help.
We started by looking at which members tend to cost a lot from year to year and have evidence of opportunities for quality improvement defined by things such as readmissions, quality parameters that aren't being optimized and medication adherence issues. When you look at those members, typically there are three common factors among them--multiple chronic diseases, an inadequately addressed or completely undiagnosed behavioral health or substance abuse issue, and a high amount of life stress that's not compensated for by the members' coping mechanisms or support systems.
For example, think about two people, each who have depression and diabetes and arthritis. Picture one of those people as someone in an intact marriage, excellent family income, has good employment and a strong support system of family and friends. The other person has the same health problems, but is a single parent, has a low income and a teenager with real problems.
Who is likely to do better at coping with their disease burden? Typically these members have so much going on that even when physicians recognize a high-risk situation, they don't have the resources to do the requisite amount of follow-up, hand holding and support that these members need. And so that's why a lot of these folks have avoidable problems.
FHP: How do you identify members eligible for the program?
Sarran: The identification of appropriate members begins with a set of proprietary analytics that look at cost, quality and utilization issues. That generates a list, and then we take that list and work with the physicians to validate the data.
After the physician looks at the list, validates that the member is appropriate, he or she calls the patient. Basically, the conversation goes, 'Mrs. Jones, I've been reviewing your records and your care and wanted to let you know that I have a new resource in my office, a nurse care manager, who is helping me take better care of people who have multiple problems such as yourself. I'd like to have you come in, meet the care manager and review your conditions to see if we can set up a care plan that's built around your particular needs to do a better job of managing your conditions.'
These are people who are in distress, so when the physician calls and says 'I think I can help you,' the receptivity is pretty high.
FHP: What kind of training does HCSC provide nurse care managers? Are they required to have any previous experience or specific backgrounds?
Sarran: We do ongoing training for our nurse care managers. What we need are people who are pretty darned good at communicating with both physicians and patients. And they also have to enjoy doing a lot of communicating. They can come from a variety of different backgrounds. It's more the mindset, the desire and excitement of doing this type of work that we look for.
Our training helps the nurse care managers be empathic, effective interviewers of patients to tease out an undiagnosed or inadequately addressed issue. It's not that we expect them to be psychologists, psychiatrists or social workers, but we want them to be effective at forming an empathic, therapeutic relationship with the patient and the physician so it sets the context within which we make sure behavioral health and substance abuse issues are teed up.
We also support our nurses with our behavioral health unit, which provides a fair amount of detailed knowledge around our network for behavioral health, so they can suggest a specific list of available in-network providers who have expertise addressing the patient's specific issues.
The nurse care manager then ensures the visit actually occurs and that there's follow up. We often see that after people get a referral to see a physician, they either don't go at all or they don't follow through to fruition. So it's the nurse who has the time and skill set do the follow-up work.
FHP: What kind of results has HCSC realized through its medical home program?
Sarran: We have successfully reduced costs by as much as 20 percent for these high-risk patients. The program also has led to a rise in presenteeism and a more than 50 percent drop in lost workdays at Boeing.
And we've seen some increase in appropriate costs, such as medication adherence, primary care visits and behavioral health utilization. Those are all appropriate because people like we're describing are often not adhering to their meds, haven't successfully prioritized and organized their life around managing chronic disease. So that's the initial increase in spend. And then what we saw downstream is reduction in avoidable hospitalizations and emergency room utilizations. That's of course the underlying thesis of these programs.
The program is better than self-funding; it's cost saving. This is a sweet spot here in terms of the quality and cost opportunities available. It's a great value creation opportunity.
FHP: What key factors have helped this medical home succeed?
Sarran: There are a few aspects. One is targeting the right people, the people who are very likely to continue to have problems that can be better addressed than they are currently. Second, the structure of the program augments the physician relationship. So the resources deployed within the physician practice are really critical, creating a three-way team between the member, the nurse care manager and the physician. Third, the physicians buy into the program, including owning the initial outreach to identified members and supporting the nurse care manager.
FHP: Are there any overarching goals you hope to achieve with this program? And can it help the company realize other related cost-saving initiatives?
Sarran: Absolutely. It's continued improvement in cost and quality. We are really positive about this program because this is a population that has not been adequately addressed via what have become traditional programs, disease management and medical homes. The issue is there's a segment of the patient population that has a confluence of unmet needs and takes a lot of time and resources--way more than a physician can provide in any kind of typical setting and more than you can typically do from a telephonic disease management perspective. So it's finding this population with unmet needs.
Editor's Note: This interview has been edited and condensed for clarity.