The American Journal of Managed Care May 2015
Results From a National Survey on Chronic Care Management by Health Plans
Once members have been identified as eligible for chronic care management and matched to programs, an enrollment specialist will contact them for program recruitment. Our survey data show, however, that approximately 42% of health plans report substantial challenges to recruitment because of missing or invalid contact information or members not responding to repeated outreach attempts. In response, health plans have started using a wide variety of channels and touch points for their initial outreach, including mailings, online support tools, calls from trained recruitment specialists or chronic care management nurses, and tailored interactive voice response calls. Also, the timing of outreach matters, as calls immediately after hospital discharge are viewed as more successful than those unrelated to hospitalization. Several case study plans in our study place nurses in hospitals for recruitment into case management, where in addition to participating in the patient’s discharge planning, they refer members to the plan’s case management program (if appropriate) and obtain valid contact information for future communication.
Even if plans reach members, not all are willing to join a program. Those who are moderately ill are typically the hardest to engage because they are commonly asymptomatic and do not perceive a need to improve their health. For members who do join a program, surveyed plans report limited patient engagement (83%), health literacy (67%), and readiness to change (58%) as the main obstacles to improving chronic care. In response, 71% of surveyed plans state that they have learned that the “flexibility to tailor interventions to patient needs and readiness” is key to successful chronic care management. Following these lessons, plans are experimenting with new initiatives. One case study plan reported success with prescripted text messages that are sent every week (similar to a “tip of the week”) to members with diabetes to help with adherence and lifestyle change. Another case study plan is transitioning toward high-touch personalized interactions in its chronic care management programs, making its programs as accessible as possible by extending outreach hours, putting case managers into provider practices and emergency departments, and experimenting with technology (eg, chat rooms for younger members).
Finally, incentives are viewed to be an important way to engage patients. Almost half of the surveyed health plans (48%) use incentives within their chronic care management programs. Figure 2 shows the types of incentives used by plans; these incentives are primarily tied to enrollment into or completion of a program and less often to actual health outcomes.
Provider Engagement in Chronic Care Management
The need for coordination with providers was named by 38% of plans as the most important factor to make chronic care management programs work. Interestingly, small plans (less than 200,000 members) were more likely than larger plans (more than 1 million members) to name it as a critical factor (71% vs 17%, respectively).
Figure 3 depicts the most common ways in which health plans work together with providers in managing patients with chronic disease. Survey data show that almost all plans send reports on care gaps, such as failure to refill chronic medications regularly, and the frequency of these care gap reports varies across plans. Among plans that offer such reports, 84% provide them at regular intervals, 16% on demand only, and 12% both at regular intervals and on demand. Over half of plans are actively working with their contracted providers on practice redesign models, such as patient-centered medical homes.
About two-thirds of plans (63%) in the survey stated that provider reluctance to change affects chronic care manage-ment program operations; many providers, they note, prefer to focus on their traditional encounter-based approach as opposed to population management. During one case study, we were told that smaller practices and providers close to retirement are especially reluctant to change their established practice models, as are those that had negative experiences with capitation models in the 1990s. Sixty seven percent of surveyed plans reported that limited provider capabilities, such as overextension of staff and lack of patient registries and electronic medical records (EMRs), present barriers to effective chronic care management.
Emerging Practices in Chronic Care Management
Our findings suggest that health plans are in the process of changing their approach to chronic care management, taking approaches that range from supporting currently existing models of care delivery to outright redesign.
Increased collaboration with providers. Four-fifths of the plans in our study stated that they attempt to integrate their chronic care management programs into provider work flow with 2 approaches. The first taken by 24% of plans is virtual integration, which happens either telephonically or by using information technology such as EMRs. The second implemented by one-third of plans is to embed health plan staff into practices and other care settings. For example, some case study plans mentioned locating utilization management and behavioral health specialists in hospitals to assist members with discharge planning, while another plan places care management staff in practices with a high volume of its members. Staff members then educate patients with complex chronic conditions on program offerings and other support resources. A quarter of the plans combine both approaches.
Practice redesign. Health plans are making substantial efforts to redesign the current payment and delivery systems to align them more closely with the needs of chronically ill patients. Three-fourths of all plans in our sample stated that they are working on reforming the current fee-for-service approach, and all 6 case study plans were at various stages of transitioning away from pure fee-for-service payment. Most case study plans also encourage practices to adopt patient-centered medical home models that offer continuous management of patient needs, team-based care, and expanded access, including same-day appointments, after-hours care, and electronic visits. To support the transition process, more than half of the plans in our sample (52%), including all 6 case study plans, offer providers staff resources, change management consulting, tools, and subsidies for adoption of health information technology.
Use of patient support technology. Numerous technologies to support chronic care and to motivate patients to adopt healthy behaviors are being offered or developed. These range from telemedicine solutions that allow remote interaction with providers, to remote monitoring products that transmit vital signs and other biometric data to providers from devices like scales, glucose meters, and heart-rate monitors. More recent developments include social media applications that allow patients to communicate with peer groups and other online communities. While patient care technologies are not yet widely adopted, some health plans are using or piloting them in their chronic care management programs.
About half of the plans said they used remote monitoring technology (56%) and online self-administered behavior change applications (48%), while 16% of plans reported using mobile health technology such as smartphone applications. During the case studies, we also learned that plans regard remote monitoring as a promising option, especially after hospital admission, if the patient has a provider who is able to respond to the data feeds.
Multiple case study plans mentioned upcoming pilots to test new tools, and some were even in the process of launching specific technology applications, including mobile phone applications and telemedicine on a broader scale. Two plans have started offering secure video chats for higher-risk members.
Survey respondents felt that patient care technologies showed great promise and that the role of technology would increase in the future. Many plans stated that they expected to expand the use of patient care technologies within their chronic care management programs and were interested in other plans’ experiences, particularly with smartphone and social network applications.
Focused interventions. We found that health plans are increasing their efforts to tailor interventions to members’ needs. Approximately four-fifths of plans use predictive modeling to identify patients for disease management (84%) and case management (76%). Plans are also working on differentiated algorithms to predict high-cost events like exacerbations and hospital admissions, and to identify specific gaps in care, such as lack of follow-up after hospital discharge. Identification algorithms are becoming more complex. Whereas historically, claims data were the main source of information, plans are experimenting with adding other data sources, such as health risk assessments, electronic lab data, and member self-reported information, which the industry sometimes refers to as “Big Data.”
More in-house delivery of chronic care management programs. Health plans’ chronic care management programs are administered either in-house, using the health plans’ own staff, resources, and facilities, or outsourced to a third-party vendor that specializes in those services, such as a disease-management vendor. In our sample, while the majority of plans (72%) had both in-house and outsourced components, we observed a trend toward insourcing. Thirty-eight percent of plans are bringing more of their chronic care management programs in-house compared with 4% that have increased outsourcing. We learned that cost considerations and the complexity of coordinating services with outside vendors are driving the trend forward to bringing programs in-house.