Remember that scene in the movie As Good as It Gets, where the harried young mother complains she has to take her asthmatic son to the emergency room because her HMO wouldnt let him see a specialist? Like much of what comes out of Hollywood, the scene was entertaining, but not based in reality.
Contrary to the HMOs-as-bean-counters image typically portrayed by movies and TV shows, the basic premise of managed care is to give patients the right care, at the right time, in the right setting. Through new approaches to delivering care, such as medical care management, health plans strive to keep employees healthier and to help those with asthma and other chronic conditions manage their illnesses so they can avoid time-consuming, costly visits to the hospital.
Medical care management is a quality initiative which combines preventive medicine, early detection of disease and coordinated treatment processes. Thanks to recent advances in information technology, health plans can now collect and analyze claims and other data to determine who is suffering from a chronic condition or may be at risk for a particular illness. Armed with that data, health plans then work with employers to design appropriate preventive measures and clinical interventions.
For instance, asthmatic patients may be trained to avoid asthmatic attacks, monitor their breathing, and use their medications wisely. Nurse case managers would follow up as appropriate to monitor treatment and reinforce patient education, as well as coordinate care with physicians. Physicians and nurses are also educated on cutting-edge ways to prevent and control asthma.
Care management programs focus on the major cost drivers in the medical delivery system, such as diabetes, asthma, low back pain, cardiovascular diseases and hypertension. Chronic conditions such as these, which collectively account for about 60 percent of medical costs in the United States, exact a heavy toll on employers through time lost from work, reduced productivity and higher insurance premiums.
Low back pain, for instance, is second only to the common cold as the most frequent cause of work absenteeism, and is the fifth most common reason for a physician visit. Asthma, a chronic inflammatory disease that afflicts roughly 15 million Americans, causes more than 1.5 million days of lost productivity annually. It is estimated that per capita health costs are three-and-a-half times higher for diabetics than for those who do not have the disease.
Although still in its early stages, care management has already shown great promise for improved prevention and patient self-care, fewer hospitalizations and shorter lengths of stay for sick employees and lower costs for employers.
Jannifer Harper is medical director of CIGNA HealthCare of Ohio.
Making a difference
Through care management programs, health plans have implemented new research findings and emerging scientific evidence to care for costly chronic conditions. Preliminary indications are that these programs result in better medical outcomes, improved quality of life and reduced employer costs.
- CIGNAs Lovelace Health Systems in New Mexico has experienced an 83 percent decline in lost school, day care and work days among children with asthma and their parents.
- In Memphis, CIGNAs low back pain care management program resulted in 17 percent fewer hospitalizations and a 16 percent decrease in emergency room visits. Employers medical costs for low back pain also declined 16 percent.