U.R.N Programs for Specific Diseases: Congenital Heart Disease Resource Services (CHD)

Half of the referrals for pediatric heart transplantation are for congenital heart disease. For these cases, corrective surgery may be a viable alternative to transplantation. Treatment for complex CHD cases averages $290,000 per episode – or $1.16 million per 100,000 covered lives. Clinical and financial outcome data reveals that experience with CHD surgery creates value in all dimensions. This is the basis for the U.R.N. CHD Centers of Excellence Network. There are seven centers across the United States that meet the rigorous evaluation criteria specific to CHD. The surveys and criteria are reviewed annually by the U.R.N. Clinical Sciences Institute and their advisory panel for CHD.

The average length of stay in a CHD COE network facility is 16 days vs. 29 days in a non-COE Network facility. The decreased length of stay, in addition to the average of 40% discount U.R.N. has negotiated with the CHD COE Network facilities, leads to a total average cost of $106,873 vs. $290,000 per surgery.

You may visit www.urnclient.com to view the volume data, outcome data, and credentialing criteria for the U.R.N.’s CHD Centers of Excellence Network. Volume and outcome data might be helpful information to share with members and their physicians.

Why Manage Chronic Disease?

  Employers, insurers and federal lawmakers increasingly are focusing on early intervention for potential chronic diseases to avoid hospital admissions and complications later in the disease process. Disease management is one of the fastest-growing areas in health care.

Federal Efforts

The federal government launched a disease management initiative to test capitated payment arrangements with qualified organizations for the case management of specific diseases. The targeted populations include Medicare beneficiaries with chronic illnesses and special populations, such as those eligible for both Medicare and Medicaid and the frail elderly. Historically, a small proportion of Medicare beneficiaries has accounted from the major proportion of Medicare expenditures. In 1996, 12.1% of all Medicare enrollees accounted for 75.5% ($126.1 billion) of all Medicare fee-for-service program payments.1   

Many of these beneficiaries have specific, chronic diseases and the majority of the care is for repeat hospitalizations. As the general population continues to age, the estimated cost of care for these individuals is expected to grow dramatically.

Private Sector Efforts

The level of interest regarding disease management is increasing. The Disease Management Association of America was formed to advance the practice of disease management and the National Association of Quality Assurance has established standards for disease management programs. Managed care organizations usually have some form of disease management programs in place, since there are clear incentives for managing care effectively. The  programs may be internally developed or outsourced to a disease management vendor.

Program Features

The definition of disease management and the program objectives may vary, but there are certain features that are common to all programs:

• Identification of members and assessment of severity and the need for interventions
• Use of evidence-based practice guidelines
• Monitoring compliance with the plan of care
• Promoting patient self management
• Routine reporting and feedback with patients, physicians, the health plan, and ancillary providers
• Collection and analysis of process and outcomes data

Programs may include the use of information technology, such as specialized tracking and documentation software, data registries, automated decision  support tools, and call-back systems.

Chronic Diseases

The majority of disease management vendors offer programs for asthma, diabetes, cardiovascular disease (congestive heart failure, hypertension), chronic obstructive pulmonary disease, maternity management (including high-risk pregnancy), and end stage renal disease.

Intervention

Levels of intervention are offered, ranging from distribution of educational information to frequent phone contact with patients and physicians. The level of intervention provided is based on the assessed needs of the  patient. Many disease management vendors now offer predictive modeling as a part of their programs. The predictive modeling system can analyze data from a variety of health plan sources to identify the patients who are consuming the greatest portion of healthcare dollars and have the greatest potential for future complications and admissions. This information can then be used to focus disease managementefforts on patients who have the greatest need and who offer the potential for the greatest return on investment.

End Stage Renal Disease

Among the chronic diseases typically managed by disease management firms, the diagnostic group that is most likely to result in a reinsurance claim is end stage renal disease (ESRD) with resulting dialysis. The average monthly cost for an ESRD patient is $15,000 to $40,000. The average time on the kidney transplant waiting list is 5 years. In addition, the majority of these patients have co-morbid conditions, such as hypertension, diabetes and cardiovascular disease, which result in costly hospital admissions. Eight out of every 100 Americans have some form of kidney failure.2   By 2010, 725,000  people are projected to have ESRD and to need dialysis or a transplant.3  ESRD cost the U.S. health care system nearly $19.3 billion in 2000. Costs are projected to double by 2010.4,5   The management of ESRD patients can vary widely, so having an ESRD disease management program is beneficial to a health plan where this disease is prevalent in the population.

Sources:

1. Federal Register Notices, Vol. 68, No. 40, February 28, 2003.
2. NKF-K/DOQI estimate.
3. USRDS 2003 ADR Report.
4. Hostetter, NKDEP presentation, 2003
5. Trivedi, et al, Am J K D, Vol. 39, No. 4, 2002

Summit ReSources Portfolio of Services

As a result of the survey and client conversations, the following Summit ReSources portfolio of services was structured.  Each vendor underwent a stringent due diligence process. An onsite visit to the primary facility providing the service was part of the process for the majority of the vendors. If you would like to learn more about any of the programs or have any questions, please contact Debbie Stubbs or Laura Pearce.   If there are other programs you think we should consider adding to Summit ReSources, please let us know. Transplant Management

United Resource Networks (URN)

URN offers consulting expertise and access to over 100 of the nation's most prestigious medical centers specializing in organ and tissue transplantation. Specialized Physician Review services are also available, whereby our customers can obtain independent, expert medical opinions of the appropriateness of proposed transplants for     specific members and in the area of congenital heart disease.

URN also has a Congenital HeartDisease program, which includes   access to a network of facilities that excel in the treatment of congenital heart disease (CHD).  The CHD programs complement the heart transplant expertise found within the URN transplant network.

Claim Recovery

Health Decisions, Inc. (HDI)

HDI specializes in benefit management services that produce a 3:1    return on investment within 12 months, while leaving current coverage intact.  HDI provides claim recovery and enrollment support services.

Disease Management

See related article (click here).

National PPO Network

GlobalCare, Inc.

By offering access to a 24-hours-a-day, 7-days-a-week Medical Help Desk, as well as through relationships with over 100 PPO networks andnegotiators, GlobalCare allows your members to have medical assistance and network access anywhere in the United States and around the world.

Predictive Modeling

Integrated Healthcare Information Services, Inc. (IHCIS)

Impact Pro is IHCIS’s industry-leading, rules-based predictive modeling tool that produces a measure of future relative risk, a prediction of future health care costs,  relative risk for an inpatient admission and the probability of one or more admissions for each   enrolled member of a health plan. These measures of risk can be used in medical management and have financial, actuarial and underwriting     applications. Impact Pro is used by leading health plans and clinicians across the United States, serving more than 30 million Americans.

Non-Network Claims Management

Global Claim Services (GCS)

GCS specializes in clinical and financial claims reviews, offering a personalized, process-oriented approach for out-of-network medical claims and fee negotiations for inpatient and out-patient facilities, professional services and ancillary fees.

Neonatal Intensive Care Management

See related article (click here).

Catastrophic Illness and Injury

Paradigm Health Systems, Inc,

The highly skilled staff specializes in management of a variety of catastrophic medical events, such as brain injuries, spinal cord injuries, complex burns and severe trauma.

Summit ReSources Portfolio of Services: Disease Management

Cost savings from proactive disease management coupled with patient self management through education: Health Management Corp., Inc.

This award-winning health and disease management company addresses high-cost, high-impact conditions to achieve definitive value for health plans, employers and government entities.  Disease management is available for asthma, congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, diabetes, low back pain and metabolic disorders (e.g. obesity).

Quality Oncology

Quality Oncology, a subsidiary of Matria Healthcare, Inc., is the largest and most experienced provider of comprehensive cancer treatment support programs. Quality Oncology’s approach utilizes the expertise of seasoned oncology nurses and physicians, assisted by a state-of-the-art, web-based Integrated Care Management system with embedded evidence-based cancer treatment guidelines.

Matria Healthcare, Inc.

Total Health Enhancement Solution includes a combination of preventive, educational and care management services and programs designed to curb costs while improving employee health. Programs include maternity (including gestational diabetes and high-risk pregnancy), neonatal intensive care, asthma, chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure,   diabetes, depression, acute low back pain, and obesity management.

United Resource  Networks

URN’s Cancer Resource Services program targets the relatively small number of complex cancer patients that drive the majority of the medical expense related to the treatment of cancer.

EnvisionCare Alliance, Inc.

EnvisionCare’s Kidney Management Services (KMS) program provides clinical consulting and administrative services that can reduce complications and costs associated with end stage renal disease.