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Peter J. Solomon Company was pleased to act as the exclusive advisor to Centene Corporation. Managing Director J. Andrew Cowherd, 212-508-1610; [email protected], and Associate Director Ravi Sachdev, 212-508-1664; [email protected], led the transaction for the firm. Independent, timely business intelligence on disease and demand management Volume 10, Number 15 August 10, 2005 Respiratory DM Firm Will Stay the Best-of-Breed Course Centene Inhales AirLogix in Latest DM Industry Acquisition Centene Corporation, a St. Louis-based managed care organiza tion (MCO), has acquired AirLogix, a best-of-breed disease management (DM) firm focusing on respiratory diseases. The acquisition marks Centene’s first entry into the DM space, according to company sources. The MCO historically has provided Medicaid and Medicaidrelated programs to organizations and individuals through governmentsubsidized programs. Centene says it acquired Dallas-based AirLogix pri marily to expand the company’s product line of specialty services, which is managed by CenCorp Health Solutions, a wholly owned subsidiary of Centene. Under the terms of the agree ment, Centene paid about $35 mil lion in cash for AirLogix. The deal provides for additional financial con siderations of up to $5 million if AirLogix achieves certain undis closed performance criteria. Centene estimates that the acquisition will initially generate annual revenues of about $18 million for the firm but will have a nominal earnings impact on the MCO in 2005. Michael Neidorff, Centene’s chairman and chief executive officer, says the acquisition of AirLogix was made to support the company’s strat egy to build a multi-tiered, integrated healthcare enterprise that will enable the firm to consistently manage healthcare costs on a sustainable and long-term basis. In particular, the combination of AirLogix’s DM experience and Centene’s financial strength will allow Centene to better serve its expanding Supplemental Security Income membership, a pri mary market segment for the firm, while supporting AirLogix’s existing customer base, he says. Susan Riley, chief executive officer of AirLogix, says the firms strong track record of posting suc cessful financial and clinical out comes has made it a prime acquisi URAC Targets Outcomes, Care Coordination in New DM Standards Greater emphasis of disease management (DM) outcomes meas urement methods and coordination of care management services beyond DM programs are two of several key proposed changes included in the second generation of URAC’s DM accreditation standards. URAC has released the draft standards for public scrutiny and is inviting comments on them by DM organizations and others in the healthcare community by August 25. The revisions to URAC’s DM accreditation standards are the first to be made to the standards since they were first introduced in final form in April 2002 (DMN, 4/25/02, p. 1). The changes in the second generation of standards were made largely to reflect transformations that have occurred in the DM land scape in the last three years, accord ing to John DuMoulin, vice presi dent of government relations and continued on page 4 tion target in recent years. “The main reasons for being acquired are sim ple,” she tells DM News. “We were a privately held company that never had plans to go public, so an acquisi tion/merger was a natural evolution of the business. We were growing our top line by 40 percent year over year, so we have been profitable and attractive to potential buyers. Our investors are very pleased.” Riley also says the acquisition gives the niche DM firm additional resources that will enhance its ability to manage the health concerns of people with chronic respiratory dis eases such as chronic obstructive pulmonary disease and asthma on a much larger scale than it has been able to in the past, particularly with the Medicare market. “We know that we have a unique approach in the industry and wanted the resources and size to take that approach to as many people as possible,” she explains. “We believe strongly that one of the reasons we did not receive continued on page 4 IN THIS ISSUE Study Casts Doubts on DM’s ROI Claims .......................................2 CMS Picks Health Hero for Medicare DM Demonstration ...2 First Medicare Health Support Programs Take Flight .............3 Canadian DM Data Project Could Have Benefits South of the Border .......................................7 DM News Briefs .......................8 A U G U S T 1 0 , 2 0 0 5 Study Casts Doubts on DM’s ROI Claims Despite the many claims of pos itive returns on investment (ROIs) being made by disease management (DM) organizations, the evidence of the economic impact that DM pro grams are having is scarce, accord ing to researchers from Cornell University and Thomson Medstat. Their review of 44 studies ana lyzing the economic impact and ROIs for DM programs revealed mixed results for programs targeting depression, diabetes and asthma, but positive ROIs for programs targeting congestive heart failure and multiple illnesses. (See Figure 1, page 3.) “Our interest was in reporting whether assumptions about the posi tive economic impact of DM pro grams correspond to actual results from well-designed studies that used rigorous methods,” explains chief researcher Ron Goetzel, director of the Institute for Health and Productivity Studies at Cornell and vice president of consulting and applied research at Ann Arbor, Mich. based Thomson Medstat. “There was also a desire to inform public policy experts about private sector innova tions in DM, and to learn whether these innovations might hold promise for Medicare and Medicaid patients.” The project sheds light on DM ROIs, but it does not provide con clusive findings about whether they are predominantly positive or nega tive because relatively few econom ic analyses have been conducted, says Goetzel. Making things more difficult, many of the studies that have been done have involved a small universe of subjects, and the DM programs that were analyzed varied significantly in format, he adds. “Overall, there has been little scientifically rigorous research con ducted to determine the financial impact of disease management,” Goetzel says. “That’s a concern, because companies and government agencies have increasingly adopted DM to control the cost of care for individuals with chronic medical conditions -- a minority of the pop ulation responsible for a majority of healthcare spending.” In the study, Goetzel and his research team found that: • The cost of DM programs for congestive heart failure averaged $1,399 per participant, and savings averaged $3,884. The average ROI, achieved in a little less than a year, was $2.78 in savings per dollar spent on the program. Four of the five studies that used the optimal research design produced a positive ROI. • Many of the studies that looked at DM programs for asthma showed savings, but only two of the better-designed studies delivered enough savings to produce a positive ROI and these studies covered very few cases. • The results for diabetes were too variable to provide conclusions. • Among programs managing patients with multiple diseases, the ROI ranged from $4.37 to $10.87 in continued on page 3 CMS Picks Health Hero for Medicare DM Demonstration The Centers for Medicare and Medicaid Services (CMS) has selected a consortium of healthcare organizations led by Health Hero Network to demonstrate how physicians can use home health monitoring technology to help Medicare beneficiaries with chronic illness lead better lives while reducing costs for Medicare and its beneficiaries. Joining Health Hero Network in the consortium are the American Medical Group Association, Bend Memorial Clinic in Bend, Ore., and Wenatchee Valley Medical Center in Wenatchee, Wash. The organizations have named their project ACCENT -- Advancing Chronic Care through EHealth Networks and Technologies. ACCENT is one of six demonstration projects that CMS awarded as part of its Care Management for HighCost Beneficiaries Demonstration, which will test the ability of direct-care provider models to coordinate care for highcost/high-risk Medicare beneficiaries by providing them with clinical support beyond traditional settings to manage their diseases and illnesses (DMN, 12/10/04, p. 2). Health Hero joins RMS Disease Management as the only DM-related firms to receive project awards under the demonstration (DMN, 7/10/05, p. 8). As with other DM-related firms participating in CMS’ planned and ongoing care coordination and DM demonstrations and programs, Health Hero and RMS will have the opportunity to showcase the financial and quality of life benefits that DM programs can produce for Medicare fee-forservice (FFS) beneficiaries. In the ACCENT project, Health Hero Network’s Health Buddy home health monitoring system will support physicians at medical groups in Oregon and Washington in coaching and 2 D I S E A S E monitoring high-cost Medicare patients to help them stay healthy and out of the hospital. “Doctors and patients, supported by technology, will work together to transform how we care for people with complex chronic illness,” says Steve Brown, president and chief executive officer of Mountain View, Calif.-based Health Hero Network. “We’ve helped improve the quality of life for thousands of veterans through our work with the Veteran’s Administration. We’re excited about having a similar impact on the lives of thousands of other American seniors in Medicare.” ACCENT has developed a technology-based care management process that it will use to care for up to 2,000 patients with congestive heart failure, diabetes, chronic obstructive pulmonary disease or any combination of those diseases. The goals of the project are to demonstrate improvements in quality of life and care for enrolled patients and a minimum 5 percent net savings in Medicare costs of caring for those patients. ACCENT organizations and all other awardees under the demonstration will receive a monthly fee for each beneficiary participating in the program to cover their adminis trative and care management costs. The three-year demon stration program is scheduled to begin in January 2006. While enrolled in the demonstration, patients will be given a Health Buddy home health monitoring appliance, which physicians and nurses will use to coach patients on preventive behaviors. The caregivers at the two medical groups will then track patients using the Health Buddy sys tem’s web-based software to give them immediate data they can use to spot problems early and, therefore, prevent crises that could lead to unnecessary ER visits and hospital stays. continued on page 6 M A N A G E M E N T N E W S A U G U S T ROI continued from page 2 savings per dollar spent on these pro grams over an average of 1.4 years. • DM programs targeting depression consistently cost more - about $500 more a year -- than they saved in direct medical costs. However, these programs may deliv er a positive ROI if the impact on patients’ day-to-day functioning, absenteeism and overall productivity is factored in. Although it is clear that DM programs can deliver significant health benefits, employers and health plans still need a sound business case to continue offering these programs, Goetzel believes. “More and better research on the business case is required,” he says. Although Goetzel’s research team did not intend to identify ingre dients of successful DM programs, their review uncovered several themes and strategies common to successful programs that DM organi zations may find useful in their plan ning and operations: • Offering individualized and personalized risk-reduction counsel ing to those at highest risk. • Developing appropriate clini cal guidelines based on the best sci entific evidence and updating them as needed. • Educating and involving physi cians and other providers on effective implementation of these guidelines. • Conducting repeated evalua tions. 1 0 , 2 0 0 5 • Sharing results with providers and patients. • Leveraging information sys tems to identify patients for interven tion and measure clinical and finan cial outcomes. • Providing “self-management” education to teach patients problemsolving skills. • Using organizational change interventions, including the use of separate clinics devoted to preven tion, planned care visits for preven tion, patient reminders and nonphysician staff to carry out specific prevention activities. • Effectively screening and triaging patients into risk-specific interventions. • Using tailored materials founded on behavior change theory. • Using goal setting by patients. The complete study findings appear in the summer issue of Health Care Financing Review and are available online at cms.hhs.gov/ review/05summer. Contact: David Wilkins, Medstat, (734) 913-3397, [email protected]. • Figure 1: Summary of DM ROI Analysis for Selected Diseases Average Per Participant Cost and Savings Disease State Asthma Average ROI Total Benefits/ Costs Number Avg. Sample Size for Intervention Avg. Evaluation Period (Yrs.) Cost Savings 2 5 2 3 12 34 149 1471 144 449 1.0 2.3 1.1 0.8 1.3 $ 292.54 525.10 — 256.36 268.50 $ 1,067.74 (98.48) 557.29 1,390.64 729.30 3.65 (0.19) NA 5.42 2.72 RCT(A) RCT(B) CBA Pre-Post Total 4 1 4 3 12 92 49 314 226 170 0.7 1.5 0.6 0.6 0.9 $ 464.50 1,190.00 1,018.00 2,715.15 1,399.22 $ 1,700.25 15,500.00 1,490.09 8,461.75 3,884.03 3.66 128.90 1.46 3.12 2.78 RCT CBA (A) CBA (B) Pre-Post Total 4 1 1 2 8 608 3,118 732 3,585 2,011 2.1 2.0 5.0 0.9 2.5 $1,862.33 580.50 — — 610.71 $(1,013.25) 1,294.32 817.50 637.50 434.02 (0.54) 2.23 NA NA 0.71 Study Design RCT (A) RCT (B) CBA Pre-Post Total CHF Diabetes Notes: ROI is return on investment. RCT is randomized clinical trials. CBA is controlled, before and after study design. NA is not applicable. Source: Return on Investment in Disease Management: A Review, Health Care Financing Review, Summer 2005. First Medicare Health Support Programs Take Flight The nation’s first Medicare Health Support (MHS) programs officially began operations on August 1 in Maryland/Washington, D.C., and Oklahoma. The new three-year voluntary pilot programs, being administered by Nashville, Tenn.-based American Healthways in Maryland and Washington, D.C., and by LifeMasters Supported SelfCare in Oklahoma, will serve up to 20,000 fee-for-service Medicare beneficiaries in each area. Under the MHS programs, the two disease management (DM) firms will provide Medicare beneficiaries suffer ing from diabetes and congestive heart failure (CHF) with health information, education and special services to help them take better care of their individ ual health needs and adhere to their physician’s plan of care. American Healthways’ program will offer self-care guidance and sup port to chronically ill beneficiaries to help them manage their health, adhere to their physicians’ plans of care, enhance the patient-physician relationship, and ensure that benefi ciaries seek and obtain Medicarecovered benefits that will help reduce their health risks, according to Kriste D I S E A S E Goad, a spokesperson for American Healthways. Beneficiaries who agree to participate will receive regular phone calls from a team of RNs, reg ular health information mailings and on-site nurse visits to beneficiaries in long-term care facilities, she says. The program’s managers and caregivers also will apply real-time data and customized reports to help track patient health information and progress toward specific goals between office visits, Goad adds. The program also features a dedicat ed program manager to help identify continued on page 6 M A N A G E M E N T N E W S 3 A U G U S T Centene continued from page 1 a Chronic Care Improvement Project was due to our being small with a corresponding balance sheet. We want the Centers for Medicare & Medicaid Services to know that we can handle the scale and the financial risk associated with these programs and demonstrate that our approach is ideal for the Medicare population.” Although AirLogix is now part of a larger organization with a stated strategic goal of creating a multi tiered entity, Riley expects AirLogix to stay the course with its best-of breed focus on respiratory diseases. “I believe that being a DM company with a single disease focus did limit us from a market size perspective to some degree -- the size of the respi ratory disease market is, of course, much smaller than that of the [total] chronic disease, wellness and pre vention market. But we will always remain true to the best-of-breed model that provides deep interven tion, including home visits when appropriate, to optimally impact a person living with chronic illness. We will not veer from our proven model.” Riley believes there is “ample business” for both best-of-breed and one-stop shops in the DM space. “I truly wish we would stop trying to put the business into an either/or sit uation where one will ultimately win out,” she tells DM News. “It is not URAC continued from page 1 product development for URAC. The enactment of the Medicare Modernization Act of 2003 with its Medicare Health Support programs [formerly Chronic Care Improvement Programs], the call for greater accountability in DM outcomes measurement, a surge in consumerdirected healthcare, and the imple mentation of the HIPAA privacy and security measures are four prime examples of major system changes that have occurred since URAC’s DM standards first came on the scene, DuMoulin says. How well a DM organization coordinates care beyond their bor ders to other healthcare programs and organizations during a patient’s 4 1 0 , 2 0 0 5 good for our customers, our patients or the industry to make every model the same. There are different approaches for different needs.” For example, an employer may be comfortable with a very “light touch” model that uses only tele phonic intervention to interact with a participant, while a government payer source may be more interested in a streamlined approach that reach es all the way into the communities and patients’ homes to achieve the desired outcomes, she explains. “In all areas of healthcare, there are gen eralists and specialists -- physicians, hospitals, pharmaceuticals, home health -- all of these sectors have both approaches. That is because of the vast array of different needs to be met. One size simply cannot fit all in healthcare and disease/population management, nor should it.” Riley believes Centene recog nized this when it chose to acquire AirLogix. “Centene acquired us because of our DM capabilities. They view us as a platform from which to launch many new products and serv ices. We feel honored. They currently have some disease management pro grams in their local markets, and we will be identifying ways to incorpo rate the best practices of all.” Centene sees AirLogix’s servic es as a proven way to control their medical management costs internally as the DM firm provides services to their health plans, according to Riley. As part of Centene’s specialty prod ucts division, AirLogix will join a behavioral health company, a nurse line and a prescription compliance company in this division, she says. “We anticipate working closely with the other companies to complement our suite of services and assist them in growth,” Riley says. “While pro viding services for Centene plans, we will also continue to pursue com mercial, Medicaid managed care, Medicare Advantage and fee-for service opportunities in the market as we always have.” Riley says she will remain chief executive officer of AirLogix and the rest of the DM firm’s management team also will remain in place. The only major change she expects to see as a result of the acquisition is more business for AirLogix. “We antici pate only growth, so do not expect any changes to our employees’ status other than much more opportunity as we grow the business. [Centene] rec ognizes our superior performance in disease management and wants us to build on those results. We couldn’t have asked for a better outcome to our years of hard work in a difficult industry.” Contact: Robert Schenk, Centene Corporation, (314) 725 4477, [email protected]; Susan Riley, AirLogix, (214) 576-2067, sri [email protected]. • transition of care is a new point of emphasis in URAC’s standards, according to Annette Watson, a vice president for URAC. In Standard 7, URAC is now proposing that a DM program establish and implement policies and procedures for coordi nation of services with DM pro gram participants and other healthcare programs and organizations, including procedures for communi cating with those programs and organizations when the program participant is transferred to another program or his or her DM benefit is terminated. Clarification of how DM pro gram performance requirements are established and measured is another key enhancement to the proposed standards, says Karen Fitzner, direc tor of research and program develop ment for the Disease Management Association of America (DMAA), who served on URAC’s DM stan dards review committee. For exam ple, proposed Standard 2 would require DM practices for each clini cal condition to be reviewed by a clinical content expert with expertise in the relevant clinical condition. “These new revised standards encourage more attention to proper research methods and study design that will benefit the disease man agement community as well as patients with chronic illnesses,” Fitzner says. “The evidence-based focus will also enhance care for those with chronic illness.” Among the other major pro- D I S E A S E continued on page 5 M A N A G E M E N T N E W S A U G U S T URAC continued from page 4 posed changes of note in URAC’s draft DM accreditation standards: • Two new definitions have been added to the glossary, for “out come” and “valid.” (See sidebar.) • Recognizing the trend toward consumer-directed care, Standard 5, formerly labeled Shared DecisionMaking, has been renamed Consumer Decision-Making, and several other references to “shared” throughout the standards now spec ify that the “consumer” is the pri mary focus of the standard. • Standard 16, which formerly addressed stratification and assess ment of eligible DM program par ticipants, has been split into two separate standards, with Standard 16 addressing stratification and a new Standard 17 addressing assess ment. (See sidebar.) This addition raises the total number of URAC’s DM accreditation standards to 23 from the original 22. URAC is encouraging broad public comment on its proposed DM accreditation standards through August 25 using an online com ment form available on the organi zation’s web site, urac.org. The Washington, D.C.-based organiza tion also will accept comment by email ([email protected] with the subject line Comments -- DM Standards), standard mail or fax. To ease reviewers’ understand ing of the changes, URAC has developed a crosswalk between the two versions. It is also available on the organization’s web site. The standards are designed to accredit the full spectrum of organi zations providing DM, Watson says. To encourage innovation in DM, the standards are not diseasespecific, which differentiates them from those of rival accrediting organizations such as NCQA and JCAHO, she explains. They apply to all types of organizations provid ing DM services, including health plans, stand-alone DM organiza tions and medical management organizations, Watson says. “That is what sets URAC’s disease management accreditation apart,” she tells DM News. “Companies offering a wide array 1 0 , 2 0 0 5 of disease management services, including leading-edge programs in areas such as childhood obesity, behavioral health or end-stage renal disease, can benefit from URAC’s disease management accreditation. It’s not for diabetes or asthma serv ices alone.” Watson says URAC shaped many of its DM accreditation stan dards using DMAA’s definition of DM as a rough template. URAC adopted DMAA’s definition with its initial set of standards to promote consistency in the industry, so organizations that meet that defini tion of DM are eligible to apply for accreditation by URAC, she says. “URAC’s disease manage ment accreditation does not make what we believe to be confusing distinctions between what type of organization is providing the serv ices,” Watson explains. “URAC is most interested in ensuring that disease management services in any setting are held to the same rigorous standards.” Contact: Annette Watson, URAC, (202) 216-9010, [email protected]; Karen Fitzner, DMAA, (202) 778 3297, [email protected]. • URAC’s Draft DM Standards Add New Definitions URAC’s proposed disease management (DM) accreditation standards include two new definitions to the standards’ glossary that reflect the greater emphasis on DM program measurement. • Outcome. A measure that indicates the result of the performance (or nonperfor mance) of a program, service or intervention. The evaluation methods may include clin ical, financial, utilization, economic, quality and humanistic outcomes (e.g., patient or provider satisfaction). • Valid. Based on accepted principles of study design, research methodology and statistical analysis. Source: URAC, Disease Management Standard Version 2.0, Public Comment Draft Proposed Standards Separate Stratification, Assessment of Eligibles DM Standard 16: Stratification of Eligible Consumers The disease management program implements a process for stratifying a popula tion of eligible consumers into groups that: • Defines criteria for each level of stratification and identifies at which levels eligi ble consumers will receive an individual assessment. • Is based on written criteria that define data sources for conducting the stratifica tion process. • Includes an initial stratification of eligible consumers that can be used to priori tize contacts with consumers. • Is conducted according to timelines that require the disease management pro gram to complete the stratification and assessment processes within a specified period of time after identification of eligible consumers. • Ensures that co-morbid conditions are identified, documented. and considered in the assignment of interventions. • Includes periodic restratification, which must be at least annual. • Incorporates evidence-based tools where available. DM Standard 17: Assessment of Eligible Consumers The disease management program implements process for conducting interac tive individual consumer assessment for consumers identified in Standard 16: • Identifies tools and methods to be used for conducting individual consumer assessments that are specific to the consumer’s clinical condition. • Documents the results of individual assessments conducted. • Includes a mechanism by which stratification level and associated interventions can be adjusted based on individualized assessment or other data. • Includes periodic reassessment, which must be at least annual. • Incorporates evidence-based tools where available. Source: URAC, Disease Management Standard Version 2.0, Public Comment Draft D I S E A S E M A N A G E M E N T N E W S 5 A U G U S T Health Hero continued from page 2 Donald Fisher, president of Alexandria, Va.-based AMGA, applauds CMS’ willingness to look at creative approaches to managing high-risk patients with chronic dis ease and conditions. “The ACCENT Project will demonstrate that doctors and patients with severe chronic ill ness, supported by information tech nology, can establish a new partner ship to provide exceptional preven Medicare continued from page 3 6 2 0 0 5 tive care for patients in their homes and keep them healthier and living independently longer while reducing costs,” he says. In addition to its latest DM demonstration award, Health Hero Network is participating as a sub contractor in two Medicare Health Support projects serving up to 180,000 additional Medicare bene ficiaries patients around the coun try. Those beneficiaries will receive chronic care improvement services through DM organizations and health plans that Health Hero is working with. Contact: Kathy Goodman, Health Hero Network, (650) 559-1034, [email protected]; Julie Sanderson-Austin, American Medical Group Association, (703) 838-0033, [email protected]; Cynthia Mason, CMS, (410) 786–6680, cmhcb [email protected]. • Figure 1: Program Features of Medicare Health Support Programs patients who are not following rec ognized standards of care, she says. LifeMasters’ MHS program will make use of the DM firm’s supported self-care model that centers on edu cation, medication compliance and behavior change, according to Barbara Gideon, a spokesperson for the Irvine, Calif.-based DM firm. The program will also establish a team of local and call center-based nurses, physicians, pharmacists and health educators in Oklahoma to administer the program, according to Gideon. In addition, it will emphasize physician communication by developing cus tomized care plans, alerts and deci sion support applications and by eas ing physicians’ access to patient care records and biometric monitoring data, she says. And as part of the physician outreach component of the MHS program, LifeMasters also will conduct in-person orientations about the program for high-volume physi cian practices, Gideon says. With the MHS programs, CMS hopes to improve the health and qual ity of life of Medicare beneficiaries and to reduce the amount of state and federal money spent on costly, yet avoidable, medical procedures, hospi talizations and emergency room visits by helping beneficiaries actively pre vent complications that can arise from chronic diseases. The programs are two of nine MHS programs being launched by CMS in various regions of the coun try for about 180,000 beneficiaries with diabetes and CHF. Although all of the MHS programs will target pri marily those two diseases, how they go about managing them will be continued on page 7 1 0 , Chronic Care Improvement Organization AETNA Inc. American Healthways CIGNA Health Dialog Humana LifeMasters McKesson Visiting Nurse Service– EverCare/Unit ed HealthCare Services XL Health Geographic Areas Served Program Features • Advance Practice Nursing Program for home health and nursing homes • Customized care plans • Caregiver education • Blood pressure monitors and weight scales provided based on participant need • Physician communication • Physician web access to clinical information • 24-hour nurse line • Personalized care plans • Direct-mail and telephonic messaging • Supplemental telephonic coaching • Gaps in care generate physician prompts • Intensive case management services as necessary • Remote monitoring devices (weight, blood pressure and pulse) based on participant need • Physician web access to clinical information • Physician communication • 24-hour nurse line • Personalized plan of care • Telephonic nurse interventions • Oral and written communication in addition to telephonic coaching • Home monitoring equipment (weight, blood pressure and glucometers) based on participant need • Intensive case management for frail elderly and institutionalized participants, as required • Data exchange with physicians • 24-hour nurse line • Personal health coaches develop individual care management plans • Health education materials (web-based, faxed or mailed) • In-home biometric monitoring • Behavioral health case management and intensive case management as needed • Data exchange with physicians, • Active involvement of other community agencies • 24-hour nurse line • Trademarked Personal Nurse program model • Group education and support sessions • Biometric monitoring equipment, including glucometers and weight scales as necessary • Core telephonic support supplemented with RNs, social workers and pharmacists in the field interacting with providers and beneficiaries with complex needs • Data exchange with physicians • On-site meetings with physicians and CME programs • Physician web access to clinical information • Electronic medical recordkeeping systems will be piloted in five small physician-group practices • Active involvement of other community agencies • 24-hour nurse line • Single nurse as primary contact for beneficiary • Supported self-care model including education, medication compliance, behavior change • Home visits as appropriate • Team of local and call center-based nurses, physicians, pharmacists, and health educators • Digital weight scale and blood pressure monitors • Physician communication including customized care plans, alerts, decision support applications; access to patient care record and biometric monitoring data • Physician outreach includes in-person orientation for high-volume physician practices • Physician web access to clinical information • Active involvement of other community agencies • 24-hour nurse line • Extensive physician involvement, including on-site staff support • Data exchange with physicians, • Physician web access to clinical information • Telephonic outreach • Mail, fax, workbooks • Remote monitoring and biometric equipment for selected high-risk participants • Pharmacist review of medications and collaboration with physicians • Management of long-term care residents and intensive case management, including end-of-life • 24-hour nurse line • Home health agency leading outreach in community • Management of high-risk participants who require extensive in-home management • Telephonic outreach and health risk assessments • Use of SmartCards to use at physician visits and hospital admissions to track service use and convey embedded information to providers • Physician web access to clinical information • Active involvement of other community agencies • 24-hour nurse line • Biometric monitoring including glucometers and weight scales as necessary • RNs, social workers, and pharmacists in the field, interacting with providers and beneficiaries with complex needs Source: Centers for Medicare & Medicaid Services D I S E A S E M A N A G E M E N T N E W S Selected Chicago Counties Maryland and Washington, D.C. Northwest Georgia Western Pennsylvania Central and South Florida Oklahoma Mississippi Brooklyn and Queens, N.Y. Selected Counties in Tennessee A U G U S T Medicare continued from page 6 largely up to each program. Details about the scope and plan of opera tions for the nine MHS programs has been sketchy up to this point, but a recent CMS transmittal shed consid erable light on who plans on doing what. In a July 22 transmittal to Medicare fee-for-service providers, CMS detailed the features that each MHS program is expected to include. (See Figure 1, page 6.) All 1 0 , 2 0 0 5 MHS programs will make use of the standard 24-hour nurse call lines that are the staple components of most DM programs today, but several pro grams will call upon some innovative tools and strategies. For example, Visiting Nurse Service of New York, in partnership with United HealthCare Services Inc.-Evercare, will use “smartcards” at physician visits and hospital admissions to track service use and convey embedded information to providers. Meanwhile, Humana will pilot test an electronic medical record (EMR) system in five small physician-group practices to assess whether and to what extent an EMR system can benefit DM programs for Medicare beneficiaries. Contact: Kriste Goad, American Healthways, (615) 263-7524, [email protected]; Barbara Gideon, LifeMasters Supported SelfCare, (650) 829-5287, [email protected]. • Canadian DM Data Project Could Have Benefits in U.S. Four provinces in Canada are developing a novel chronic disease management (DM) infostructure that could hold lessons for DM providers in the United States. Called the Chronic Disease Management Infostructure (CDMI) initiative, the project is an undertak ing of the Western Health Information Collaborative (WHIC), a group of deputy health ministers that is working together to explore col laborative opportunities with respect to health infostructure initiatives. Four Canadian provinces have com bined their efforts to assess their cur rent state of chronic DM (CDM), develop business requirements and define an information management framework aimed at ensuring stan dardized information exchange of clinical DM data. The four provinces participating in the initiative are British Columbia, Alberta, Saskatchewan and Manitoba. “The primary objective of this initiative is to develop common data standards and information exchange protocols and provide support for the implementation of these standards at a regional and/or provincial level,” says Michael Hurka, project director of the CDMI initiative. “This will promote the need for action on advanced and complex components of the electronic health record (EHR), such as chronic disease man agement, concurrent with many jurisdiction specific actions on EHR building blocks such as registries, diagnostic imaging and pharmacy.” Hurka says developing and implementing a chronic DM infos tructure is a key component of estab lishing an effective chronic DM pro gram nationally in Canada. And, if successful, it will be a significant accomplishment. “The success of the development and integration of this infostructure in four quite different provinces, as part of a multi-jurisdic tional collaboration, is a major achievement,” Hurka tells DM News. To date, the project has deliv ered a current state assessment, busi ness requirements and an informa tion management framework, according to Hurka. Current project activities are focused on defining the data standards for three specific chronic conditions -- diabetes, hyper tension and chronic kidney disease. “The definition of standards for these three conditions is being done in the context of a generic model for chronic conditions,” Hurka explains. “Even though the WHIC-CDM Infostructure initiative is focusing on these three specific conditions, there is an expectation that the standards and messages defined through this project can be easily extended to enable information exchange for other chronic conditions.” Those same standards and mes sages could also extend south to ben efit DM programs in the United States, Hurka adds. Message definition for the proj ect is being done using the latest ver sion of HL7, an international stan dard for health information exchange. “It is anticipated that by using this widely accepted interna tional standard for CDM data exchange, the standards developed D I S E A S E by the project can be positioned for broader acceptance and uptake,” Hurka says. The content of the data stan dards and the HL7 message specifi cations are expected to be finalized shortly, and the CDM infostructure is expected to be implemented by March 2006, according to Hurka. Over the next few months, the proj ect will also be working with the electronic medical record (EMR) software vendor community in Canada to understand their collective readiness to implement HL7 mes sages, he adds. “Once the message specifications are completed, they will be widely shared with the EMR vendor community,” Hurka says. “Vendor engagement is important because as more software products are able to support standardized elec tronic message exchange, the ability to share chronic disease data between increasing numbers of care providers and locations will be enabled.” Clinical software solutions and the messages they send and receive will be key components of the CDMI, Hurka says. Each province has selected two sites for initial implementation of CDM software. Provinces and health authorities will be working with their respective service providers and/or vendors to ensure that their applications are compliant with the CDM data stan dards and are capable of exchanging this data via HL7 messages, he says. “Real-time access to relevant chronic disease data will assist pri continued on page 8 M A N A G E M E N T N E W S 7 A U G U S T Canada continued from page 7 mary health care teams in providing care to individuals with chronic con ditions,” Hurka says. “The impact on the EMR vendor community will be the opportunity to incorporate stan dardized messaging that has been developed collaboratively into their products using HL7.” In addition, he says, “the project 1 0 , 2 0 0 5 is expected to have a positive impact on clinicians, who will begin to see the capability to exchange CDM data in a standardized way. This is a criti cal prerequisite in building towards an EHR that will incorporate chronic disease information and will facilitate the exchange of information across Canada. Common standards and messaging that supports primary healthcare strategies will encourage the development of interoperable EHRs and the capability to put appropriate clinical information in the hands of care providers who need it, when they need it.” Contact: Michael Hurka, WHIC Chronic Disease Management Infostructure Initiative, (780) 415 1412, [email protected]. • DM NEWS BRIEFS Health Dialog picked for NHS project. England’s National Health Service (NHS) has selected Health Dialog Services Corporation to partici pate in NHS’ Predictive Risk Project. The project will address the rising healthcare costs associated with chron ic conditions in Britain. Health Dialog will work with New York University to develop predictive modeling algorithms that will be used to identify patients at high risk of emergency hospital admis sion. The project is planned to be com pleted by January 2006. The NHS for mulated the Predictive Risk Project to help identify patients at highest risk of future emergency admission in order to ensure that case management services are targeted most effectively and that people receive appropriate healthcare interventions at the right time. The risk prediction system will be used by Primary Care Trusts, which are physi cian organizations under the NHS that are responsible for managing primary care in a given geographical area. Contact: Palmer Reuther, Racepoint Group Inc., (781) 487-4606, [email protected]. will be implemented during the first quarter of 2006. Collectively, the new employer, health plan and biopharma accounts and the additional covered lives from the expanded accounts will represent approximately 375,000 addi tional covered lives for the DM firm. Contact: Stephen Mengert, Matria Healthcare, (770) 767-4500, [email protected]. Healthways signs deal with Alameda. American Healthways has signed a new, two-year agreement to pro vide its StatusOne high-risk care man agement program to Medi-Cal benefici aries of Alameda Alliance, a Californiabased, not-for-profit health plan serving more than 91,500 Alameda County resi dents. The new agreement begins Sept. 1, 2005. Under the arrangement, American Healthways will support a specific group of beneficiaries of Alameda Alliance’s managed Medicaid program, Medi-Cal, who are at highest risk for acute and high-cost health episodes. Contact: Kriste Goad, American Healthways, (615) 263-7524, Matria inks seven new deals. Matria Healthcare Inc. has signed seven new DM accounts, say officials with the Marietta, Ga.-based DM firm. The company also has expanded the scope of contracts with three existing customers. Matria’s seven new con tracts are with five self-insured employers, one biopharma company and one regional health plan. The three awards of expanded business are with self-insured employers. By policy, Matria does not disclose the names of its customers. Two of the seven new accounts have been implemented, and Matria expects to implement services for the other five new accounts during the third and fourth quarters of 2005 and the first quarter of 2006. One of the three expanded accounts has also been implemented, and the other two 8 D I S E A S E [email protected]. Independence Blue Cross adds Accordant’s DM programs to portfo lio. Philadelphia-based Independence Blue Cross (IBC) has expanded its DM offerings to plan members to include DM programs for uncommon complex conditions such as rheumatoid arthritis and multiple sclerosis. The expansion is the result of an agreement between IBC and Accordant Health Services under which the Greensboro, N.C. based DM firm will add its DM pro grams to IBC’s existing portfolio of DM services. IBC began providing its members and physicians with the expanded DM services last month. They are expected to affect about 20,000 people in health plans adminis tered by IBC. IBC’s two-year old DM initiative currently provides DM pro grams for coronary artery disease, chronic obstructive pulmonary disease, congestive heart failure and diabetes. Contact: Liz Williams, Independence Blue Cross, (215) 241 2220. • ©Copyright 2005 National Health Information, LLC, P.O. Box 15429, Atlanta, GA 30333-0429; phone (404) 607-9500; fax (404) 607-0095. Publisher: David Schwartz. Editor: Tony Sullivan, phone (630) 665-7510; fax (630) 665-7580. Contributing Editor: Russell Jackson. Subscriptions cost $397 a year for 24 issues via first-class mail; add $10 for Canadian and $25 for international. FEDERAL COPYRIGHT RESTRICTIONS Disease Management News is a trademark of National Health Information, LLC. Reproduction or redistribution of this newsletter in whole or part by photocopying, entry into a data retrieval system, or any other means is a violation of federal copyright law and is strictly forbidden without express prior per mission of the publisher. All rights reserved. (ISSN 1084-7146) • VISIT OUR WEB SITE AT www.nhionline.net M A N A G E M E N T N E W S