Prevention and wellness programs take priority for health plans

ALTHOUGH A RECENT STUDY reported in the Journal of the American Medical Association shows that less than half of eligible Medicare beneficiaries received six recommended preventive services, such as cancer screenings, flu shots and diabetes eye exams, health insurance plans are illustrating that prevention and wellness programs are a priority. The study by the Center for Studying Health System Change also shows that suboptimal care exists even in higher income areas.

The U.S. Preventive Services Task Force is taking up the cause with plans to expand its guidelines for doctors and health plans next year, indicating when patients should receive tests for 16 medical conditions, including skin cancer, hip problems, iron disorders, peripheral artery disease and genes linked to breast cancer.

In addition, the National Committee for Quality Assurance (NCQA) has added new Care Management and Health Improvement standards as part of its Quality Plus program, including identifying members who smoke, recruiting them into smoking cessation programs and sending reminders for preventive screenings. Thus far, 57 health plans have signed on as early adopters.

"Today, there is more of an emphasis on drivers of cost inflation, which are primarily drugs and hospital services associated with chronic disease. Prevention is not that closely linked to inflationary costs. In addition, ROI from prevention is long-term," Dr. Ho says.

On the other hand, Andrew Baskin, a senior medical officer for Hartford, Conn.-based Aetna, says that there is just as much emphasis on preventive services as there has always been-in fact, evidence-based practice guidelines have enhanced preventive care-but that the efforts are just not receiving as much notice as disease management. "We haven't backed off; there are proven benefits to immunizations and screenings for cancer, cholesterol and blood pressure," he says.

Louisville, Ky.-based Humana has developed an unusual alliance with Virgin Group Ltd., the innovative British airline and music company. "Virgin is aligned with our focus on delivering value to customers," says Jack Lord, senior vice president and chief innovation officer at Humana. "Virgin came to us to administer a plan making health fun."

The result is a fitness program using Virgin's HealthZone, a tool that centers around a state-of-the-art body pod that tracks an individual's blood pressure, weight and body mass index (BMI). Participants may earn points for filling out a health risk assessment, working out, tracking progress and making a change in a physiological parameter. The points translate into cash and special discounts for items such as fitness apparel. It will be offered first quarter 2006 in San Antonio, Texas, and Tampa Bay, Fla.

Humana has taken another step in the direction of preventive care-the creation of a joint Health Services Research Center with the University of Miami Leonard M. Miller School of Medicine. The collaboration will develop strategies to maintain health and improve the management of chronic illness based on outcomes.

The health plan also is piloting a Personal Nurse service in Miami that puts advice nurses in physician offices instead of offering information via the phone.

CareSource, the state of Ohio's largest Medicaid managed care organization, has teamed up with the Ohio Tobacco Use Prevention and Control Foundation. CareSource based in Dayton and other participating insurers will foot the cost of nicotine patches with the Foundation. As of July, 363,000 Ohioans qualified for the 18-month program through CareSource.

Jon Keeley, CareSources' director of pharmacy, says the pilot's primary goals are to evaluate the success of the patch in conjunction with the telephone quit line and the overall cost-effectiveness of the program. There has already been a 42% increase in requests for the patch. "We identified those already using a patch and encouraged them to call the toll-free quit line," he says.