Health/Disease Strategy

The real potential for the application of incentives, rewards and recognition programs is in the broader context of overall employee health, as well as benefit programs and retirement planning initiatives driven by consumer directed healthcare strategies.

Case management is critical to help measure a hospital's success in quality care and financial stability. As noted by the Case Management Society of America, a case manager must be an advocate for both hospital and patient.

As employers search for ways to reduce rising healthcare costs and improve employee productivity, more companies are implementing wellness programs in an attempt to improve employees' health and reduce their own insurance costs. There are a number of different options employers may consider when deciding to institute a wellness program, including offering smoking cessation and weight loss programs, fitness classes, and in some cases, penalizing certain behavior. Employers must be careful, however, to ensure that these programs do not violate certain federal and state laws as they carry certain inherent legal risks.

Dallas-Recently released results of a consumer survey show that a majority of Americans believe more emphasis on preventive medicine is a solution to the increasingly evident problems of the nation's healthcare system.

As the abundance of cliches would indicate, incentives are a powerful force. Health incentives, however, are becoming more sophisticated, and stakeholders need to adopt programs that work.

As durable medical equipment (dme) becomes increasingly sophisticated, MCOs' challenges remain rooted in establishing medical necessity. To that end, most use strategies including prior authorization and coverage limits. Meanwhile, they must also satisfy changing state and national regulatory requirements.

Disease management-or, what we have known as disease management-stands at a crossroads, as changing demands in the marketplace and a growing emphasis on wellness and prevention recast our thinking on chronic care. Can DM survive?

Washington, D.C-Employer-sponsored health-insurance plan premiums increased only 6% in 2007, less than the last four years. However, insurance costs are rising much faster than inflation and wages, according to a leading survey of employer health benefits. Premiums now average more than $12,000 for family coverage (almost $4,500 for individuals), pricing many workers out of the market.

Pat Ford-Roegner, MSW, RN, FAAN, CEO of the American Academy of Nursing (AAN), seems a natural fit for her latest appointment as a member of the new Washington, D.C.-based Partnership to Fight Chronic Disease (PFCD) Advisory Board. The board, led by Richard H. Carmona, MD, MPH, FACS, former U.S. Surgeon General, is comprised of 40 high-profile CEOs and presidents from the public and private sector.

The need to reauthorize the State Children's Health Insurance Program (SCHIP) by September 30, has evolved into a broader debate about the role of government in providing healthcare to Americans. The Bush administration wants to maintain a limited program for low-income children, while Democrats envision more open-ended coverage for more children and families.

Coffee shops, restaurants and grocery stores have started getting serious about employees washing their hands to prevent the spread of germs. If the guy who steams my cafe latte remembers to scrub his hands for 30 seconds before getting behind the coffee counter, then why aren't more healthcare providers remembering to do it?

The economics and the politics behind the major healthcare problems affecting men, such as cardiovascular disease, cancer, obesity and depression, aren't receiving the attention they deserve. It has been the rule that women make health decisions for themselves and also for their male partners and their children. In contrast, most men have a more casual attitude toward their care: "if it ain't broke, don't fix it."

Newly diagnosed patients with chronic conditions wait an average of 105 days until someone reaches out to them with disease management support. Precious time is lost, affecting their health, attitude and openness to change.

NATIONAL REPORTS-For chronically ill patients, increased cost sharing can be associated with lower rates of drug treatment, less adherence among existing users and more frequent d iscontinuation of therapy, according to research published in a recent issue of the Journal of the American Medical Assn.

Ann Arbor, Mich.- In the past, plans provided electronic explanation of benefits to consumers, which reflected a major customer service innovation. Today, innovations involve enabling consumers to connect their physicians and other care providers with a comprehensive information repository enriched by the data managed by the plan-including medical and drug claims, lab results, and health risk information, industry experts say.

Grace seems an unlikely acronym for a study of acute coronary events, but given the findings of the Global Registry of Acute Coronary Events published in the Journal of the American Medical Association, the name may be apropos.

More than half of all state Medicaid programs incorporate a financial incentive encouraging providers to deliver better quality care, according to a study by the Commonwealth Fund. In addition, the study finds that 70% of existing Medicaid P4P programs operate in managed care or primary care management environments. Nine Medicaid programs are joining with other payers, employers and providers in statewide or regional P4P efforts, which is an indicator that the Medicaid plans are keeping pace with HMOs-half of which are offering P4P programs of their own.

Worldwide, 388 million people will die from chronic diseases in the next 10 years. Chronic diseases account for about 75% of all healthcare costs. Clearly, disease management and prevention is sorely needed, but it's been a struggle to change the behaviors of large groups of people. A number of programs are finding success using non-traditional methods.

Every morning, Mark Wagar, president of Empire Blue Cross Blue Shield, walks more than a mile through Manhattan to his office on 42nd Street. It's a city of great diversity and that fact that isn't lost on him, especially considering that one in four New Yorkers is an Empire member.

Last month, the LA Times reported that Blue Cross of California had agreed to change its position on policy cancellations, now making a distinction between those who make honest mistakes on application forms and those who fraudulently misrepresent themselves to obtain benefits. The Times predicted that the class-action settlement would "send shock waves" through the insurance industry.

LOW-PREVALENCE rheumatoid arthritis (RA) has not gained attention equal to that of more common chronic diseases, but it has earned a spot on the list of complex diseases ripe for disease management.

LOW-PREVALENCE rheumatoid arthritis (RA) has not gained attention equal to that of more common chronic diseases, but it has earned a spot on the list of complex diseases ripe for disease management.

As more health plans turn to automated, speech-enabled calls to reach out to members with welcome programs, preventive health reminders, or with more sensitive information about a specific condition, they must use an appropriate approach. Done correctly, such phone programs can provide a cost-effective way to speak with members.

DOUGLAS E. HENLEY, MD, BELIEVES that the U.S. healthcare system is so fragmented, so disjointed and so disorganized that he finds it hard to even refer to it as a system.

Despite a mounting clamor for reform from many health policy experts, Senate action to reduce payments to Medicare Advantage may be postponed this year. Influential senators oppose an across-the-board cut, which would reduce MA plan activity in rural and low-cost regions.

NATIONAL REPORTS-Corporate wellness programs are top-of-mind for the majority of large, and even many mid-size employers, according to industry experts.

DIABETES, ASTHMA cardiovascular disorders, high-risk pregnancy and chronic obstructive pulmonary disease (COPD), will continue to account for anywhere between 55% and 70% of medical costs, according to industry experts. For these disease states, executives are taking a look at more creative DM programs, but they also are seeing emerging diseases on the horizon.

Disease management as we now define it may be on its last legs, though no one knows it yet. The Disease Management Purchasing Consortium has noticed that the savings in all but a few diseases doesn't offset the costs, and nowhere does it generate the level of return on investment (ROI) that some people think they are getting.

Care management has become an increasing challenge for America's healthcare system. Given the open-access approach and flexibility in allowing consumer choice, how do preferred provider organizations (PPOs) approach the issue of coordinating care for chronically ill beneficiaries? In 2005, more than 133 million Americans had one or more chronic conditions. Their care accounted for 83% of all healthcare spending. People with chronic conditions tend to have multiple illnesses and multiple providers, making care coordination that much more critical and challenging for all stakeholders. Some key approaches used to coordinate services in PPO models of healthcare include utilization management (UM), case management (CM) and disease management (DM). In addition, PPOs are adopting strategies to identify high-risk patients early and to prevent the onset of chronic conditions.

The State Children's Health Insurance Program (SCHIP) will expire September 30, 2007, unless Congress approves legislation reauthorizing this popular program offering healthcare services for children and some adults. The deadline puts this issue at the top of the Congressional agenda as an opportunity for Democratic leaders to increase public access to care. Efforts to expand coverage for children and secure the Medicare program are important to the managed care community because the legislators are eyeing "overpayments" to Medicare Advantage plans as a possible source for some $50 billion to fund SCHIP and other healthcare programs.