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More than just a healthcare buzzword, disease management is thought by many to be a significant part of the solution to the nation's overburdened health system.

Intuitively, it makes sense. Spend a relatively small amount of money on the front end to manage chronic conditions so that patients avoid complications and hospitalizations that are much more costly on the back end. Elevate prevention to a reimbursable endeavor and avoid some diseases altogether.

Nancy Alsgard, managing director of medical clinical strategy for BlueCross BlueShield of Tennessee (BCBST), said this concept was really the idea behind HMOs in the 1980s. However, she added, it didn't take long for the idea of "maintaining" good health to get buried under the weight of acute and chronic needs.

Now, however, Alsgard, an RN with a broad-based healthcare background that spans the spectrum from clinician to patient safety advocate to health plan executive, said the time has come for BCBST to take a leadership role in helping members truly manage their health.

"Going forward, we're not going to be seen so much as a payer but as a responsible party that's going to find ways to return our membership to health," she declared.

Alsgard said one of the first agenda items she faced after joining BCBST this past spring was to "put together the story around our healthcare continuum called Total Healthcare Management."

She continued, "We're developing the concept around the fundamental principles of education, prevention, empowerment and advocacy.

"Historically, the healthcare industry has focused on treating a disease or set of diseases. Now, it's about creating a relationship. We look at the patient holistically. We have the opportunity between our interactions with physicians and the member and with technology to look at the patient as a whole."

At the foundation of this strategy is the technology of medical informatics, which can be used for predictive modeling and for prompting evidence-based interventions.

To help BCBST pursue this path, the company acquired Gordian Health Solutions in the summer of 2005. Alsgard says her company utilizes Gordian's expertise as a wellness and prevention company to conduct risk assessments on the front end and to help create programs to address members' needs.

Looking at members as three-dimensional beings rather than as a one-dimensional set of statistics has challenged BCBST to take an integrated approach to care. Alsgard says her company realizes health is impacted by many factors. To reach members at every level, she says the company has worked to develop relationships with hospitals, physicians, employers, communities, churches, schools and legislators.

In late September, BCBST held a statewide launch of its WalkingWorks for Schools program, which was created to address the issue of childhood obesity. The original pilot program began last year in 35 schools. Of the teachers who participated in the pilot, 75 percent have already noticed physical changes among students.

Working with other partners, including hospitals, physicians and schools, BCBST was also active in helping craft national legislation introduced in both the House and Senate regarding school nutrition. The Child Nutrition Promotion and School Lunch Protection Act of 2006 seeks to update the definition of "food of minimal nutritional value" to conform with current nutritional science to ensure children have access to healthy meals.

Being involved in arenas that impact health is part of the company's commitment to the total healthcare management continuum, which runs from health and wellness to acute and chronic care to complex care to the end of life.

"Our goal is that if you came in with a chronic disease to get you back to the front end of that continuum," Alsgard said.

With diabetes, for example, she says, "There are a lot of diabetics out there who don't know how to improve their health. They don't get their eyes checked. They don't get their teeth checked. Then, the comorbidities begin to raise their heads … it just becomes a plethora of problems. Over the lifetime of a member, it's very important for us to follow them and work with them on all these other fronts.

"You don't just pay the bills … you don't just twist your thumbs and worry … because you are part of the problem if you don't address those issues," Alsgard firmly stated.

Just as commercial carriers are looking at disease management in a new light, so, too, is the federal government.

As baby boomers segue into their senior years, it becomes apparent that the healthcare system must find ways to elevate the general population's health status or risk being swamped.

Dr. David Hollis, chief medical officer for XLHealth's Medicare Health Support program, a federal disease management pilot program created by the Medicare Modernization Act, noted that we currently have about 40 million Americans in the Medicare system. Of those, approximately 5 million are in managed care and 35 million in a fee-for-service plan. However, he continued, those figures are expected to double in about 10 years.

"We will go from 5 to 13 million in the managed care population, but the numbers in the non-managed care will jump from 35 million to 67 million," Hollis said, hence the urgency to find ways to save costs.

"Paying for illness after it occurs is how Medicare has always done it," he pointed out. Now, however, CMS is looking at front-end strategies. "Disease management is no longer a theoretical concept. Now we're trying to implement it."

In Tennessee, the pilot program identified 20,000 seniors to participate with another 10,000 in the control group.

"There are two qualifying indicators for this 20,000 … they have to be either living with diabetes or heart failure," Hollis explained.

For the active participants, XLHealth goes through evidence-based guidelines to see which measures are being taken with a patient and which are not. Citing the "Quality of Health Care Delivered to Adults in the United States" report (NEJM, November 6, 2003, 349:1866-1868), Hollis says 63 percent of heart failure patients and 45 percent of diabetics do not get optimal treatment.

"That's just not acceptable," he stated.

However, Hollis added, programs like his are not designed to embarrass or hinder physicians but rather to support them in caring for chronic patients. He said XLHealth keeps the primary care physician informed throughout and encourages physician collaboration.

"There's no way a physician can provide all the information needed on a particular disease in 15-20 minutes," said Hollis. "Disease management programs provide additional coaching and counseling and help patients narrow down questions they need to ask their doctor in the 15 minutes they have."

He added that by using evidence-based guidelines as the core of their programming, "We're really helping physicians get ready for pay-for-performance whether they realize it or not."

Covering 35 counties in Tennessee including the state's four largest cities and their surrounding counties, XLHealth takes a two-pronged approach to working with patients. The first is through telephonic coach nurses, and the second is through nine assessment centers where patients have face-to-face interaction with care providers.

Hollis said the provider team completes a health risk assessment on the front end and puts together an individualized care plan.

"The frequency of calls is determined by risk stratification," he added.

To engage patients, the company uses a mixture of educational information and technology. Dieticians are available to work with participants and their caregivers. Participants are taught to look for early signs of complications. Some heart failure patients receive a special scale that asks a series of questions each day. Participants know that a two or three pound weight gain may indicate a fluid buildup that requires a medical intervention.

Participants also meet one-on-one with a retail pharmacist for a complete medicine review (including over-the-counter drugs). The information helps XLHealth gauge compliance, and the complete list is sent to the primary care physician.

If XLHealth and the other disease management companies don't perform … they pay. Hollis said each of the eight national pilot programs are charged with achieving a 5 percent cost savings vs. the control group, improving key quality indicators and improving beneficiary satisfaction.

"If we don't, then we're financially at risk to CMS," he said.

The assumption, backed by outcomes in other disease management pilot programs, is that integrated approaches such as those taken by BlueCross BlueShield of Tennessee and the Medicare Health Support programs will make a difference both in costs and in the lives of consumers.

"If we can teach people to take care of themselves … to work with their medical providers … then we're going to improve the quality of care, and we're going to reduce costs because we're going to avoid complications and hospitalizations," Hollis concluded.


Nancy Alsgard, BCBS Managing Director of Medical Clinical Strategy


November 2006

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