The American Journal of Managed Care May 2015
Comparison of Provider and Plan-Based Targeting Strategies for Disease Management
Objectives: We aimed to describe and contrast the targeting methods and engagement outcomes for health plan–delivered disease management with those of a provider-delivered care management program.
Study Design: Health plan epidemiologists partnered with university health services researchers to conduct a quasi-experimental, mixed-methods study of a 2-year pilot. We used semi-structured interviews to assess the characteristics of program-targeting strategies, and calculated target and engagement rates from clinical encounter data.
Methods: Five physician organizations (POs) with 51 participating practices implemented care management. Health plan member lists were sent monthly to the practices to accept patients, and then the practices sent back data reports regarding targeting and engagement in care management. Among patients accepted by the POs, we compared those who were targeted and engaged by POs with those who met health plan targeting criteria.
Results: The health plan’s targeting process combined claims algorithms and employer group preferences to identify candidates for disease management; on the other hand, several different factors influenced PO practices’ targeting approaches, including clinical and personal knowledge of the patients, health assessment information, and availability of disease-relevant programs. Practices targeted a higher percentage of patients for care management than the health plan (38% vs 16%), where only 7% of these patients met the targeting criteria of both. Practices engaged a higher percentage of their targeted patients than the health plan (50% vs 13%).
Conclusions: The health plan’s claims-driven targeting approach and the clinically based strategies of practices both provide advantages; an optimal model may be to combine the strengths of each approach to maximize benefits in care management.
Am J Manag Care. 2015;21(5):344-351
- Physician organizations were highly variable and differed from the health plan in their approach to targeting patients and delivering care management.
- Care management programs administered in conjunction with patients’ primary care clinical settings yielded a higher percentage and different subgroup of patients who were targeted compared with a health plan’s disease management program, with only a 7% overlap.
- Both provider-delivered and health plan-delivered care management offer advantages: the former benefits from a personal relationship with patients and important clinical information, while the latter has patients’ overall healthcare utilization history, including with providers unknown to primary care.
Americans are increasingly plagued by chronic disease,1 and evidence suggests that not all patients are receiving self-care support for managing their disease.2,3 Care management is a patient-centered approach to “assist patients and their support systems in managing medical conditions more effectively,”4 and includes patient education, goal setting, and self-management support. Active involvement of patients in their care is fundamental to the Patient-Centered Medical Home5-8 (PCMH) Model and the Chronic Care Model.9-11 However, not all individuals with chronic disease require services beyond the usual care received from their providers. Therefore, methods for successfully targeting patients to engage them in care management are increasingly important to providers, health plans, and employer groups who must optimally allocate resources.
Targeting involves identifying patients who may benefit from care management services and offering these services to them. The structure, targeting strategies, and care delivery mechanisms of care management programs are based on the goals of the organizations administering the programs. Health plans offer disease management programs to reduce costs associated with chronic disease–related adverse events among their members; their targeting strategies are driven by assessments of predicted cost risk from claims data and by employer customer preferences. Outreach and care management are delivered by trained registered nurses, primarily by phone. Although health plan disease management programs have been effective for some populations,12-15 they are criticized for not being integrated with the patient’s primary care physician (PCP).16,17
Alternatively, many primary care practices and physician groups are developing care management programs that are coordinated with patients’ ongoing care. These programs combine in-person, electronic, and phone-based management, and utilize care managers who are either embedded within the practice or located off-site. Patients are offered care management by a member of the practice team, such as a PCP, care manager, or medical assistant.
Provider-Delivered Care Management Pilot Program
In 2010, a large Midwestern health plan partnered with 5 physician organizations (POs) to implement a 2-year Provider Delivered Care Management (PDCM) pi-lot program. The pilot aimed to improve the health of chronically ill health plan members by financially supporting POs and their affiliated primary care practices in delivering care management, essentially reducing the number of members managed by the health plan’s internal disease management program. Two POs used pilot funding to develop new care management programs, while 3 expanded their existing programs. POs assumed full responsibility for administering their programs. This work developed from the plan’s overall approach of partnering with primary care to improve the quality of care. This includes a PCMH program that offers incentives to POs for increasing medical home-related capabilities, including care management, within primary care practices.18
While many recognize the importance of targeting strategies for successful care management19 including the potential benefit of predictive modeling20-22—there is sparse literature examining targeting options. In this quasiexperimental, mixed-methods study, we aimed to describe and contrast the targeting methods of the health plan model with the PDCM models to address the gap in the literature. The study was approved by the Michigan State University and the University of Michigan Institutional Review Boards.
The 5 POs selected 52 of their primary care practices for the PDCM pilot those with the capability and resources to deliver care management—with the majority (n = 42) having earned PCMH designation from the health plan.23 Given their advanced level on the PCMH spectrum, they were not representative of the nonselected practices within the pilot POs; however, they are likely similar to other PCMH practices with care management capabilities. One practice dropped out of the study in the first year and was excluded from analyses. Adult (18 years and older) health plan members were eligible for the study when they were identified as having a care relationship with a participating PCP in one of the selected practices at some time during the 2-year pilot, and had health plan-delivered disease management coverage under their employer group benefit. A care relationship was inferred via a claims-based algorithm that assessed 24 months of professional claims data for specific evaluation and management services to determine the PCP most responsible for a member’s care.
A monthly list of eligible members was sent to each PO, along with demographic information (ie, birth date, gender), claims-derived risk score, chronic disease identifiers via the proprietary clinical analysis tool “Impact Intelligence” (Optum, Eden Prairie, Minnesota), and previous 12-month counts of emergency department visits and hospitalizations. This study included only the members from the monthly lists that were accepted by the POs into the PDCM pilot; a member was accepted when 3 criteria were met (Table 1). Accepted members did not necessarily receive care management, but were eligible to receive care management through their PCP’s practice. Administrative and/or data analytic staff from the POs were responsible for collecting and reporting monthly care management activity data from the practices for their accepted populations.
Quantitative Data Collection and Analysis
We calculated target and engagement rates for each PO’s accepted populations based on reported encoun-ters with care managers (Table 1). The target rate was the number of accepted members that had an outreach attempt, an outreach encounter, or a care management encounter divided by the number of accepted members. The engagement rate was the number of members that had at least 1 care manager encounter divided by the number of targeted members. Two POs each employed 2 different targeting methods; each was treated as a subgroup in analyses. We excluded from the analyses accepted patients who did not remain on the eligible patient lists for at least 2 months after their acceptance date (n = 284, or 4%).
Health plan members accepted into the PDCM were removed from the plan’s disease management targeting process; therefore, in order to compare the plan’s targeting mechanism with the POs’ methods, the plan’s targeting criteria were retrospectively applied to the claims of the accepted population to identify which members would have met the plan’s targeting criteria had they not been accepted into the PDCM. Thus, among the accepted population, patients either: 1) met PO/practice-based targeting criteria, 2) met plan-based targeting criteria, 3) met both sets of targeting criteria, or 4) were not targeted. We performed t tests and χ2 tests to compare patient characteristics and target rates of the POs with those of the health plan. Since the pilot patients were managed by the POs rather than the plan, we compared PO engagement rates with the plan’s overall estimated engagement rate of members not in the PDCM.
Qualitative Data Collection and Analysis
This study included data from an extensive qualitative analysis of the care management programs, collected as part of a larger comparative effectiveness study. The research team interviewed PO leaders and staff, and conducted observations at 25 of the 51 practices across all 5 POs, purposefully selected to maximize diversity across practices. Hour-long semistructured interviews with multiple practice members were conducted to elicit detail regarding their care management programs and targeting strategies. Similarly, interviews were held with 2 nurses and the program supervisor for the health plan to obtain information on the plan’s program and targeting method.
A Likert-type scale score sheet was used to quantify the presence or absence of specified care management features, including the process of accepting patients, the training and background of the care manager(s), how and by whom care management was offered to the patient, and the location, frequency, and topics covered in care management visits. Extensive notes were taken to describe each feature, and a summary report was given to each practice for member-checking.
All data were transcribed and placed into the qualitative software program ATLAS.ti (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). Three qualitative researchers coded the data after extensive group review to determine appropriate codes and establish consistency of coding. Quotation reports by POs were produced for the relevant codes and reviewed by the research team (3 coders, plus 3 other team members [including JSH]) to determine the processes of identifying and offering care management for each PO and to corroborate the scaled score items.
Practice and Population Characteristics