Chronic diseases spur a significant portion of all health spending, so managing those diseases has attracted much attention. A survey published in the American Journal of Managed Care details how health plans are approaching chronic disease management. (AJMC Article) Conducted by researchers at Rand, the survey included a telephone interview with 25 randomly selected health plans in the US regarding their commercial enrollment care management programs, along with a more in-depth study of a few plans. Every plan in the survey sample offered chronic care management. In general the care management was used for insured and self-funded groups, but some plans allowed self-insureds to opt out. Most of the efforts had a similar structure–starting with identification of members for whom chronic care management might be beneficial, either through claims data analysis or provider referral; next patients were stratified for intensity of disease and need and the intervention matched to the perceived need; and after stratification patients are assigned to one of three general levels of intervention. The lowest level is a wellness type effort, the medium risk patients get disease management protocols and the highest-risk patients get intensive case management.
These various levels of intervention also tend to have standardized features, suggesting that there is a general consensus about the type of chronic care management programs that are most likely to be successful. Plans may differ on how much they integrate the care management of different chronic conditions for the same person, such as behavioral or drug management. Almost all plans have call centers and tools to help patients make treatment decisions. A smaller number offer in-person coaching by trained clinicians. More than half the plans provide in-home services for the highest-risk patients. Engaging the identified patients is reported as still being a significant challenge. There may be errors in contact information, but more importantly, many patients just ignore repeated outreach efforts.
Even when patients do accept a chronic care management program, most plans report barriers to successful engagement, including 67% saying they face low health literacy and 58% citing low readiness to change. Most plans said they have learned that have to be flexible in how they tailor interventions to reach the most patients in a meaningful way. About half the plans use incentives, with the incentives achieved by enrollment into or completion of the program and, less frequently, to achievement of specific health outcomes. Another barrier reported by plans is provider reluctance to cooperate, although most health plans give providers information and other assistance. Current trends reported by the health plans for revising care management programs include increased collaboration with providers, encouraging providers to redesign practices to medical home or ACO models, using patient-oriented technologies to help with engagement and insourcing program management and operation.