CURRENT ISSUES
-------------------------------------------------------------------------Heart failure programme shows promise in an IPA setting
- Amanda Cameron -
D isease management (OM) is never easy, and it becomes even more difficult when conducted in the complex environment of an independent practice association (lPA). But it appears
that an IPA manager and a large OM vendor in the US have put together a congestive heart failure (CHF) programme that can improve outcomes for CHF patients in just such a setting. Executives from the two organisations presented the latest results from the programme, and described the hurdles that were overcome during its development, at the inaugural meeting of the newly formed Disease Management Association of America (DMAA) [San Francisco, California, US; October 1999].
The CHF programme was developed in 1995 by North American Medical Management (NAMM)-a unit of Phycor Inc., that manages capitated contracts for 19 IPAs in the Houston, Texas, area, and covers approximately 200 000 lives (50 000 Medicare, 150000 commercial). Two years later, NAMM decided to expand and improve the CHF programme with the help of external DM vendor CorSolutions (formerly Cardiac Solutions), a unit of Ralin Medical Inc., based in Buffalo Grove, Illinois.
Hospitalisations, ER visits cut President and chief executive officer of Ralin
Medical, Mr Peter Smith, presented the cumulative results of the programme from 1995 through quarter two (Q2) of 1999. Enrolment in the programme increased nearly 6-fold during that time, with 98 patients enrolled in 1995 and 559 enrolled by Q2 1999. Enrollees showed a roughly even split between males and females, with a mean age of 76 and 77 years, respectively.
Cumulative results for all programme enrollees at Q2 1999 showed a significant reduction in both the number and the duration of inpatient hospital admissions. compared with historical data from payor records. The number of inpatient hospital admissions per patient-month fell by 34% (from 0.079 to 0.052, respectively) and the number of inpatient hospital days per patient-month fell by 10% (from 0.349 to 0.314).
The small reduction in the number of inpatient hospital days, relative to the large drop in the number of inpatient admissions, can be explained by the fact that it is easier to prevent hospital admissions in patients with mild-to-moderate CHF than in those with severe CHF; that is, most of the hospital admissions prevented would have been those of lhl! snuril!si. uuraiiun.
Mr Smith also described how CHF programme enrollees had a lower rate of emergency-room (ER) visits than the national median for Medicare managed care. The number of ER visits per patient-month was 0.013 among programme enrollees versus a median of 0.014 for national Medicare managed care (derived from HEDIS* 3.011997 submissions from 288 Medicare managed-care markets).
1173-5503/9910243-0003l$01.00'' Adl.In .... Nltlon.1 Limited 1199. All right. r_rved
Improved functional status in 83% An important outcome of the CHF programme was
an improvement in functional status for 83% of the patients enrolled, reported Mr Smith. Among these patients, functional status, as measured by the Duke Activity Status Index, improved by an average of 2%.
This outcome was a reflection of substantial improvements in the medical and dietary management of CHF among programme participants, said Mr Smith. Notably, vasodilator medication management was much better in Q2 1999 than when the programme first started. In 1995, only 20% of CHF patients who were eligible for vasodilator therapy were actually receiving vasodilators; this proportion increased to 70% (approximating the national average) by Q2 1999. Moreover, only 5-10% of CHF patients receiving vasodilator agents were at the target dosage at the beginning of the programme, and this proportion climbed to 45% by Q2 1999. Sodium intake among CHF patients fell significantly during participation in the programme; a Food Frequency Questionnaire completed upon programme enrolment and during Q2 1999 showed a 27% drop in sodium intake.
Hybrid programme meets IPA challenges The road to success with NAMM's CHF programme
was not an easy one, said Or Pasquale Pingitore, regional medical advisor for NAMM in Houston. The programme encountered several problems and underwent quite a few changes along the way.
Notably, the IPA environment itself presents specific hurdles for any OM provider. 'The issue in an IPA is who is going to provide the care', said Dr Pingitore. Primary-care physicians are less willing to turn over care for patients with CHF than they are to turn over care for patients with more complex conditions such as IllV/AIDS. Therefore, getting full physician cooperation presents a challenge, particularly since NAMM represent'> only 15-20% of participating physicians' business.
Another major issue for an IPA is deciding who will pay for OM services. Most of the cost savings generated by OM programmes are due to reduced hospitalisation and pharmaceutical use - savings which are usually accrued by health maintenance organisations rather than IPAs.
* Health Plan Employer Data and Information Set
PhannacoEconomics & Ou!r:omes News ,. Dec 1199 No. 243
3
4 CURRENT ISSUES
Heart failure programme - continued
To overcome these hurdles, NAMM eventually developed a hybrid 'build-and-buy' programme for CHF in which care for the more difficult cases is contracted to an outside vendor.
Under the current programme, care management is shared between NAMM and CorSolutions, with NAMM responsible for class I and II patients and CorSolutions responsible for those in class III and IV. Patient education is also shared, with participating health plans looking after the education of class I and II patients and CorSolutions looking after the education of class III and IV patients. An important component of the programme is the use of a NAMM nurse as an IPAJprimary-care physician facilitator.
NAMM operates under a global capitated contract with multiple payors, and participating physicians are allocated a portion of the savings generated by the CHF programme. However, when the programme was first established in 1995, NAMM had a global noncapitated contract, and NAMM undertook to manage only those CHF patients with NYHA** class IV disease. During the following year, NAMM expanded its programme to include noncompliant class III patients using a 'visit driven' model. Then in 1997, NAMM amended its contract to capitation, and began using Ralin Medical's 'MULTIFIT' programme for CHF. In 1998, NAMM restructured its contract back to global capitation with guaranteed cost reductions and expanded its programme to include class I and II patients for a population-based management approach.
CorSolutions called in Initially, NAMM found that the programme was
only enrolling 30-40% of eligible patients, and that around 50% of enrollees had class I or II CHF. In essence, half the funds supporting the programme were being spent on the 'healthiest' patients, meaning that the costs outweighed the benefits. To alleviate this problem, resources were redistributed so that class Ill!IV patients received a high-cost intervention whereas class IIII patients received less intensive and less frequent monitoring. Such targeted intervention intensity required a risk stratification programme and prompted NAMM to find an outside DM vendor (CorSolutions) to provide the high-cost intervention.
Other challenges faced during the programme's development included friction between physicians and CorSolutions, and suboptimal outcomes data and reporting, noted Dr Pingitore. To address these problems, NAMM decided to hire an inhouse DM coordinator who would interface between the physician and the vendor, and take responsibility for programme development and operation as well as for data collection and analysis.
Finally, NAMM decided that it was necessary to address the 'physician component of the equation', said Dr Pingitore. NAMM took responsibility for guideline deveiopmenL anu upUaLing, fur physil:ian education, and for efforts to foster positive physician
PhannacoEconomics & Outcomes News 18 Dec 11199 No. 243
involvement with the CHF programme. As a result, NAMM uses its Network Advisory Committee (comprising a physician from each IPA) to tailor national cardiology guidelines for each IPA. This approach makes it very difficult for any IPA to reject these guidelines, noted Dr Pingitore. From the Network Advisor Committee, a physician champion arises who acts as a part-time medical advisor and educator of physicians. ** New York Heart Association
1173-5503199/0243-00041$01.000 Adla International Limited 11199. All righta reserved
