Trigon Blue Cross Blue Shield and Subsidiary Health Management Corp.

Narrative Description of Program

The goal of the Better Prepared Comprehensive Case Management program is to control costs associated with individuals with any of nine chronic conditions (asthma, arthritis, cancer, cardiovascular disease, chronic obstructive lung disease, diabetes, hypertension, high cholesterol, and migraines) by developing appropriate self-management skills through ongoing telephonic intervention/education by registered nurse consultants and through written health education materials.

Better Prepared accomplishes demand reduction by helping participants to make healthier lifestyle choices and learn more about self-management of their condition thereby reducing severity and incidence of medical services.  Registered nurse consultants work with participants by:

• Assessing their current health status through a physician assessment, a written self-assessment and by a telephone interview with a nurse.
• Conducting proactive health teaching via telephone a minimum of once a month.
• Reinforcing physician treatment regimens.
• Addressing lifestyle behaviors.
• Identifying appropriate community resources and/or intervention programs.
• Providing educational and emotional support.
• Monitoring their progress.
• Advising them on insurance coverage and benefit options.

Since inception of Better Prepared in 1993, more than 7,000 people have participated in the program.  Individuals are targeted for recruitment into the program through claims codes and pharmaceutical data.

Better Prepared is staffed by 20 registered nurses with a minimum of five years of clinical experience in a variety of fields including medical/surgical, critical care and women’s health.  Additionally, participants can speak to a registered nurse 24 hours a day, 365 days a year by calling a toll-free number.

A two-year study of a representative sample of participants was designed to evaluate the effectiveness of the Better Prepared Comprehensive Case Management (BPCCM) program.  Study results show documented reductions in medical expenses and in the severity of chronic conditions, as well as return on investment savings.  Study results are as follows:

• After adjusting for severity, health care expenses per participant decreased 33% after one year of program participation, while non-participant expenses increased 29%.
• Program participants reduced the severity of their chronic conditions by 46% after one year of program participation, while the severity of non-participants’ conditions increased by 12%.
• Additionally, upon program implementation, participants had chronic conditions 2.71 times more severe than non-participants.
• Return on investment was calculated at $1.30 for every dollar invested in the program.

Note:  BPCCM savings is computed by comparing the difference in one year of data collected before program implementation and one year of data collected after implementation.  Return on investment is calculated by comparing one year of BPCCM program savings to one year of program cost.

Study Summary

The two-year study period covers one-year before the implementation of the BPCCM program and one-year after implementation (see attached graphs).

Data relating to BPCCM were collected on three groups of individuals over this two-year time period:

1. Targeted but not participated
2. Participated
3. Remaining covered lives

A methodology was taken that applied a Clinical Complex Index (CCI) system to individual patients.  The CCI uses both inpatient and outpatient claims information to make complexity assignments.  The index has three clinical components that recognize important differences between patient illness levels:

1. Relative Case Complexity which reflects the clinical differences between diseases (e.g.   pneumonia is worse than an upper respiratory infection).
2. Severity-of-illness which reflects the clinical differences within diseases (e.g. a diabetic with chronic renal failure is sicker than one without complications).
3. Co-morbidity which acknowledges the existence of clinically interacting diseases in a single patient (e.g. combination of congestive heart failure and emphysema in a single patient).

• Trigon Blue Cross Blue Shield and Subsidiary Health Management Corp

The Better Prepared Comprehensive Case Management (BPCCM) programs offer assistance to participants with nine chronic conditions:  asthma, arthritis, cancer, cardiovascular disease, obstructive lung disease, diabetes, hypertension, high cholesterol, and migraines.  Overall, participants achieved a 46% reduction in severity of conditions, while non-participants had a 12% increase.  BPCCM participants registered a 33% decrease in health care costs, and non-participants a 29% increase over the same period.

Program Strengths Noted Included: A focus on nine major chronic conditions and use of case management.  There is documentation that case management for higher costs, chronic conditions is effective.  Comprehensive program.  Previous award winner for "Baby Benefits" program in 1995.  Good clinical and cost outcomes.  Long standing commitment to evaluation.  Over 7,000 participants.  Good quality graphics and educational materials.  Excellent test of Nurse Case Management model.

This is an insurance-based case management system that identifies individuals from among a pool of 53,000 covered persons with health care conditions that might benefit from nurse counseling on health behavior changes.  About 2500 individuals participate per year with a total of about 7,000 to date.  The application reports a two-year study of a representative group of participants, targeted non-participants, and other persons covered by this plan; results show reductions in medical expenses and severity of chronic conditions and a positive return on investment as a result of these cost savings.  This a good example of utilizing convenient but reasonably creditable comparison groups for program evaluation.  The case made for program effects and cost savings is relatively strong.

There is a good self-management design.  Return on investment is 1.3 to 1.  There are good outcome indicators.  There is access 24 hours per day, 365 days per year.  The emergency room visits data was particularly strong.  This is a well documented and successful program.

Concerns Observed Included: There are limits to one program intervention per year.  Progression to the mean is possible and the participation versus non-participation design is not as strong as it might be.  The study design was not discussed in detail.  We do not know for sure if there were linkages to work sites.  Raw data on medical costs needs to be shown, rather that per cent change.  To determine cost benefit, we need to know the cost of the program.  The program must be very expensive if medical costs for participants decreased 33% while costs for non-participants increased 29%, yet the ROI was only 1.30 to 1.  Participation rates were low at 5%, although in another perspective this represents a strength.