With more and more of the population focused on wellness and healthy lifestyles, health plans are doing what they can to provide and promote quality among members.
Plans are working to identify risk factors and potential problems among members, while educating them on how to access the right care at the right place at the right time.
“Plans should make sure members are focused on wellness and prevention on the front end, so they are educated and learn how to control a disease,” says Sandra Brower-Stenger, RN, MSN, the senior director of medical operations at AvMed Health Plans.
It’s worth it to encourage prevention, adds Brower-Stenger, because early treatment is much less costly and less detrimental to a member’s livelihood and quality of life.
Smart Business spoke with Brower-Stenger about how to take advantage of the quality care initiatives health plans have put in place.
What are the risks of not focusing on quality care or taking advantage of these initiatives?
Employers should encourage their employees to focus on wellness and health care from the onset of their employment. Then, employees will know how to access care and services at the appropriate times. If health related problems arise, these problems can be quite costly, even if the employee has insurance. Costs come back to the employer in the form of an experience rating, and to the employee in the form of high deductibles or high co-insurance.
Taking advantage of preventive measures on the front end is usually less expensive. For example, early detection of breast cancer via a mammogram has a lower cost and much higher success rate for survival; it can be more costly and possibly fatal if the cancer goes unchecked.
Which measure in quality care is the most important?
All measures of quality are important, but quality care measures that focus on prevention, such as immunizations, early detection or wellness, should be a strong focus. Initiatives that encourage the identification of poor lifestyle or behavior choices and then change those behaviors in order to eliminate high-risk conditions are also important.
There also needs to be a heightened awareness about measures and activities that can help members avert crises. For example, there are many diseases that people can control. Crises can be averted by educating people on how to control and live their lives within the parameters of the disease. Show them what they should and shouldn’t do, and what types of preventive services to access, i.e., obtaining specific health screening procedures or tests.
Employers can be supportive of employees who need to have preventive tests done a couple times a year. Still to this day there are not a lot of physician offices open after hours or on Saturdays. Employees oftentimes have to take time off work for these appointments if their employer is not supportive of these preventive initiatives. This can make it more difficult for employees to access these services and get the right care.
How can employers and plan members receive information on health plan programs?
Health plans educate in a multitude of ways. One way is through newsletters, which can be tailored to the specific audience. A member newsletter may talk about different disease processes, how to better understand the health care system, and what preventive activities are scheduled based on their age, gender and high risk factors.
Employer group newsletters could be geared toward items such as wellness programs, activities and initiatives to implement for the entire employee population. Employers should be educated on the health plan’s offerings, as far as wellness and prevention activities. Studies have shown that employers who support wellness and prevention activities have a much higher participation rate of employees that are engaged in wellness activities than employers with a hands-off approach.
How do plans manage costs by coordinating care?
Health plans should have different types of programs to address a variety of different issues, such as case management, complex case management or disease management programs. Disease management looks at populations of individuals with a specific disease and helps the identified members learn about their disease. For example, a health plan can look at all of the diabetics enrolled in the health plan and identify the biggest opportunities for improvement. This could be getting them a certain test, controlling test results or mass education. It’s understanding the individuals and giving them the right tools so they can better manage the disease.
Case management is a more high touch program. A member may have more complex needs, and may have challenges navigating the health care system, utilizing unnecessary resources if he or she doesn’t receive attention from the health plan. Case management works with the member and his or her physician to coordinate care so inappropriate or unnecessary services are not being delivered.
How do plans get non-compliant members involved in health care services?
Health plans should get individuals with chronic illnesses engaged in understanding their diseases and health care needs by educating them on the importance of the care, helping them understand what will happen if they do not receive this care. They should also understand how this would affect their quality of life now and in the future.
Another way to motivate members is through incentives. Members can be rewarded when they achieve a specific goal or change a certain behavior. Incentives can be money, gift cards, prizes, drawings, or even a partial reimbursement for services.
Sandra Brower-Stenger, RN, MSN, is the senior director of medical operations at AvMed Health Plans. Reach her at (305) 671-5437 or firstname.lastname@example.org.