QualCare, which administers health plans for employers across the state, is offering the members of those plans an enhanced “population health management” program designed to get people more engaged in their health — whether they’re healthy and rarely see the doctor, or are coping with a chronic illnesses like diabetes.Dr. Christopher Valerian, chief medical officer of Piscataway-based QualCare, said PHM goes beyond the more traditional disease management program that QualCare has offered for nearly a decade. Under the old approach, if a health plan member had a chronic illness, “we would reach out to you,” Valerian said. A QualCare nurse would help the individual get the right care and make appropriate use of the company’s health care network, which includes over 100 hospitals and over 31,000 physicians and other health care providers.
But if you were on the wellness side of the health spectrum, you didn’t get as much attention.
“Let’s say you didn’t go to the doctor or the ER or have medication to take, and you’re generally pretty healthy,” Valerian said. “In that case, you really had minimal interaction with our clinical staff.”
That’s about to change.
Beginning in 2015, “We will reach out to the entire population and make sure everyone is getting the appropriate resources, depending where they fall on the continuum of care.”
There are about 200,000 lives in the self-insured employer health plans administered by QualCare, including employees and dependents.
Valerian said QualCare will reach out to the members through a new “health service team model,” where the 70 nurses on his clinical staff are organized into small teams, or pods, with each pod assigned to a handful of employer groups. “This will allow them to really focus and deliver almost a concierge level of service,” to the members.
QualCare piloted the team model in 2013 and “had tremendous results from a quality, a financial and an operational perspective,” Valerian said.
But why bother trying to get healthy people more engaged with their health?
Valerian said studies have determined that “getting people earlier on in the process helps to have better outcomes — both clinical quality and financial.”
QualCare will continue to offer a disease management program, which will remain a component of PHM. The idea is to support members along the continuum of health — with a focus on moving high-risk members to lower levels of risk.
Another goal of PHM is increased member satisfaction.
“If you have a health plan that reaches out to you proactively to say, ‘Hey, can we let you know what is going on in the health plan and maybe there are some things that we can do for you that you don’t know about,’ then there is a certain level of satisfaction that goes along with that,” Valerian said.
By analyzing medical claims data, QualCare can determine who represents a high, moderate or low health risk. And everyone “is going to get some sort of outreach, some sort of resources deployed to meet their needs.”
Someone in the low-risk group, who doesn’t have a disease or take medication, “is going to get what we call lifestyle coaching,” Valerian said. A health risk assessment may reveal the individual is a smoker, is overweight or dealing with stress; lifestyle coaching by a nurse will seek to reduce these health risks.
Someone in the moderate-risk group may have one chronic condition, like diabetes, that is pretty well controlled. “The outreach here would be more of a care coordination approach: making sure you are aware of all the health benefits your employer provides and you’re using the appropriate medications.”
Someone in the high-risk group might have a cancer diagnosis, or multiple chronic conditions.
“These are people who are heavy utilizers of the health system,” Valerian said. “They may have gone to the ER six times in the last year and don’t have a primary care provider, but instead use the ER for primary care.”
This group would receive “high-intensity coaching to provide them with the tools and education they need to better manage their conditions, and to try to understand why they are utilizing the system the way they are.”
During the pilot, QualCare found PHM had a positive impact on the quality of care, such as adherence to best practices around preventive care and disease treatment, “and that is explainable by better compliance as a result of our interactions and interventions.”
The financial impact was positive, with lower overall costs for members engaged in the pilot.
Valerian said the cardiac patients in the pilot had an overall decrease in costs of about 2 percent during 2013, while for those not engaged in the pilot, costs rose an average of 14 percent over the course of the year.
He said the nurse coaches are trying to encourage members to change behaviors, like quitting smoking or taking medication regularly or exercising, and that requires an investment of time.
“It is not uncommon for our nurse to do an outreach and an initial assessment, and we may not talk about your health care for several phones calls. It may be three or four phone calls before we even talk about your diabetes. We have to build a rapport and identify the barriers that are keeping you from being successful with your health care plan.”
Participation is voluntary and the goal is a 50 percent member engagement rate — which is higher than the average participation in workplace wellness and disease management programs, Valerian said. He said the results from the pilot suggest the PHM program will have greater success than other initiatives.
Rich Weiss is president of Viocare in Princeton, which develops science-based wellness programs for employers. He said QualCare is taking the right approach with nurse coaching
“Having a personal touch is always going to improve engagement and motivation,” he said. “You have another individual on the other end, and that is really the key. Personal feedback is going to provide a better program than a very generic, ‘eat better, be more physically active’ message.”
Weiss said it’s also a good idea for QualCare to offer the services of PHM to everyone, rather than just focus on those who already have a chronic disease. He said it’s in line with a movement that is emerging in employee wellness programs, which seeks to focus on true prevention — helping people avoid chronic disease in the first place.
“If you can catch someone before they become a diabetic, that saves the employee a lot of suffering and the company a lot of money.”
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