Objectives: The growing burden of chronic disease necessitates innovative approaches to help patients and to ensure the sustainability of our healthcare system. Health plans have introduced chronic care management models, but systematic data on the type and prevalence of different approaches are lacking. Our goal was to conduct a systematic examination of chronic care management programs offered by health plans in the commercial market (ie, in products sold to employers and individuals).
Study Design and Methods: We undertook a national survey of a representative sample of health plans (70 plans, 36% response rate) and 6 case studies on health plans’ programs to improve chronic care in the commercial market. The data underwent descriptive and bivariate analyses.
Results: All plans, regardless of size, location, and ownership, offer chronic care management programs, which identify eligible members from claims data and match them to interventions based on overall risk and specific care gaps. Plans then report information on care gaps to providers and offer self-management support to their members. While internal evaluations suggest that the interventions improve care and reduce cost, plans report difficulties in engaging members and providers. To overcome those obstacles, plans are integrating their programs into provider work flow, collaborating with providers on care redesign and leveraging patient support technologies.
Conclusions: Our study shows that chronic care management programs have become a standard component of the overall approach used by health plans to manage the health of their members.
Am J Manag Care. 2015;21(5):370-376
We conducted a national survey of health plans and case studies to document current approaches to chronic care management in the commercially enrolled market segment. We found that all plans, regardless of size, location, or ownership, offer programs for members with chronic conditions. While internal evaluations suggest that these programs improve care and reduce cost, plans report difficulties in engaging members and providers. To overcome those obstacles, plans are integrating their programs into provider work flow, collaborating with providers on care redesign and leveraging patient support technologies.
The number of people in the United States with 1 or more chronic conditions is expected to grow from 141 million in 2010 to 171 million by 2030, which means that almost 1 in 2 Americans will suffer from a chronic disease in the not-so-distant future.1 In addition to affecting an individual’s quality of life, the costs associated with treating chronic conditions increase as individuals’ number of conditions increase,2 and additionally, productivity losses due to chronic diseases are projected to triple to $3.4 trillion from the current $1.1 trillion.3 Therefore, improved management of chronic conditions is urgently needed.
In the past several years, health plans have introduced efforts to achieve this goal that include health coaching for members with unhealthy lifestyles, predictive modeling to identify and support members at risk for disease exacerbation, and remote monitoring of members in the critical transition phase after hospital discharge.4,5 While examples of health plan programs can be found in the gray (and sometimes the peer-reviewed) literature, we are unaware of any systematic studies that have examined the prevalence and scope of chronic care management programs offered by health plans.
Our study goal was to conduct a systematic examination of chronic care management programs offered by health plans in the commercial market (ie, in products sold to employers and individuals). Specifically, we sought to understand the current range of chronic care management services, to document how programs engage with patients and providers, and to elicit emerging industry trends. In addition, we explored factors that can impede a health plan’s ability to design and implement effective chronic care programs.
Our study will be of interest to policy makers, providers, health plans, and other stakeholders. As a result of the Affordable Care Act, many individuals who have newly gained access to health insurance are likely to be diagnosed with chronic conditions and subsequently will require effective management. CMS is seeking to promote better chronic care management in the Medicare fee-for-service population through separate payments for such services under the current fee schedule. Finally, emerging payment and care delivery models such as accountable care organizations and patient-centered medical homes will increasingly require providers to focus on chronic care management for their patients. A better understanding of chronic care management approaches based on health plan experience in the commercial population can help to inform policy makers and providers alike.
We used a mixed methods approach that combined a telephonic survey and in-depth case studies. The study was approved by RAND’s Institutional Review Board. For the telephonic survey, a random sample (stratified by commercial enrollment) of 70 health plans in the United States was drawn from a sampling frame consisting of plans with commercial enrollment of 50,000 or more that were listed in the 2011 Atlantic Information Services Directory of Health Plans. Of note, this directory lists health plans and includes both the parent companies and their subsidiaries. We chose the parent companies as a sampling frame because, for reasons of economies of scale, chronic care management programs are typically developed and operated at that level. The sample included for-profit and nonprofit plans, as well as integrated delivery systems that combine health insurance and care provision.
Of the 70 plans in the sample, 2 were not eligible to participate—1 did not offer full medical coverage prod-ucts and 1 served only Medicaid beneficiaries. Of the remaining 68, the participation rate was 36% (25 plans), representing 51% of all commercial members in the sam-ple because larger plans were more likely to participate. eAppendices 1 and 2 (available at www.ajmc.com) summarize the sampling frame and characteristics of surveyed plans.
Participating plans were surveyed by telephone using a structured instrument. The survey was administered by a 2-person team and lasted 90 minutes. Respondents typically included the health plan’s medical director or chief medical officer, or they designated a plan representative(s). The survey focused on the commercial segment of the plan’s enrollment, with questions about the health plan, the range of its chronic care management programs, interactions with patients and providers, and factors affecting the operating environment.
For the case studies, 6 health plans from the first phase were purposefully selected: 2 regional and 2 statewide plans in different parts of the country, and 2 national plans, as described in eAppendix 3. The case studies entailed 1- to 2-day visits by a 2-person team to conduct semi-structured interviews with staff members, including management, medical directors, and chronic care program staff, as well as reviews of plan documents (eg, program materials, evaluation reports, publications). The surveys and case study site visits were conducted between 2011 and 2012.
Key Components of Chronic Care Management Programs
We found that chronic care management programs were offered by all plans in our sample regardless of size, location, or ownership status. The programs were included as standard components of fully insured and self-insured plans as well as under integrated delivery systems, but our case studies show that some health plans allowed self-insured employers to opt out
Our results suggest there is a similarity in the overall structure of health plan chronic care management programs. This “typical” structure is depicted schematically in Figure 1. The first component of this structure is the identification of all members with chronic conditions, usually based on diagnoses recorded on claims data or on direct referral from providers or other plan programs. The second component is risk stratification of those members to match interventions and resources to patient need and risk for example, using in-person interactions for members with repeated hospital admissions. Most typically, stratification is based on a combination of proprietary criteria for utilization (eg, number of office visits, hospital admissions, prescription drugs), care gaps (eg, lack of medication adherence and missed preventive services), and electronic lab data (eg, cholesterol and A1C level) when available.
Based on risk stratification, members are then assigned to 1 of 3 programs: health promotion/wellness, disease management, and case management. Health promotion and wellness programs focus on primary prevention and address unhealthy lifestyles (eg, smoking, lack of exercise) and risk factors (eg, high cholesterol, family history) through behavioral interventions that involve educational materials, individual and group coaching, and often workplace health promotion events. Disease management programs aim to improve clinical care of chronic conditions and patient self-management. Typically, call center-based nurses educate patients about their conditions and encourage them to take an active role in their management. In addition, providers are informed about gaps in care, such as overdue tests or lack of medication adherence. Finally, case management sometimes described as a more intense extension of disease management targets the members at highest risk, no matter what their underlying conditions are. After assignment, members are recruited for program participation, and upon consent, they are enrolled. As members “graduate” (ie, achieve the goals of their programs [eg, members in case management stabilizing their conditions to a level at which self-management suffices]), the plan may assign them to a different chronic care management program or even move them back to the general membership pool.