Presentation is loading. Please wait.

Presentation is loading. Please wait.

Chronic Disease Management in the U.S.A. Alicia Bengs.

Similar presentations


Presentation on theme: "Chronic Disease Management in the U.S.A. Alicia Bengs."— Presentation transcript:

1 Chronic Disease Management in the U.S.A. Alicia Bengs

2 Outline U.S. Health Care System – Insurance Grades and Report Cards Role of Levels of Prevention Costs of Chronic Diseases Disease Management (DM) – LifeMasters®

3 Health Insurance - Contractors Employer Groups (Ford, Chevron, American Express) Retirement Plans (Ohio State Teachers Retirement System) Insurance Companies (Aetna, Wellpoint, HCSC) Insurance/Providers – dual hats (Kaiser) Government (Medicare/Medicaid/Prisons – State level)

4 Providing Care Insurance Contractor $ $ Health Care Providers (HCPs) Services Employer $ Member / Pt

5 Report Cards (Part 1): NCQA & HEDIS HEDIS = health plan report card (commercial/govt) Created by NCQA ‘Voluntary’ (fees involved, 90% plans participate) Plans give NCQA their data on various HEDIS metrics Helps to standardize comparisons b/w plans NCQA  National Committee for Quality Assurance HEDIS  Healthcare Effectiveness Data & Information Set

6 Report Cards (Part 2): URAC Medically appropriate care given Standards set for specialty area (eg – Case Mgmnt, Dz Mgmnt) ‘Voluntary’ (fees involved, high participation) Show URAC use of EBP, collaboration, consumer education, shared decision-making URAC  Utilization Review Accreditation Committee

7 Providing Care Insurance Contractor $ $ Health Care Providers (HCPs) Services Employer $ Member / Pt

8 Prevention 1* (primary) – prevention of disease 2* (secondary) – early detection/treatment 3* (tertiary) – restore function & reduce complications

9

10 Chronic ConditionPrevalenceEstimated Direct Costs (Annually) Diabetes (ADA, NIH) 23.6 million$116 billion (2007) Coronary Artery Disease (AHA, NIH) 16 million$87.6 billion (2008) Heart Failure (NIH) 5 million$ 29.6 billion (2006) Asthma (NIH, EPR3) 22 million$10 billion (2007) U.S. Statistics

11 Annual Diabetes Costs $58 billion Tx of complications $27 billionDiabetes management $31 billionExcess medical expenses $58 billion Estimated lost productivity $11,744 person /year  $6649 on diabetes $ 116 billion

12 Disease Management Insurance Contractor $ $ Disease Management Company Services Employer $ Member / Pt

13 Disease Management… “a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant” Measurements (NCQA, URAC, Natl Clinical GLs) Hgb A1C test (2-4 times a year, per contract) Annual eye examination ACEI/ARB (medication)

14 DM Company Scenario Verify Pts are: On recommended medications Getting recommended tests Reducing risks: o Diet (Na+ reduction, low-fat, low-chol), etc o Exercise (with HCP oversight) o Quit smoking o Stress management

15 Process Overview Plan provides info on high risk members Company contacts individuals: Opt-in Opt-out Company & Pt/member work on health goals Company provides plan with outcomes data

16 Tools Literature (Monthly magazine) Equipment (BP cuffs, scales) Phone calls - Coaching Model Motivational Interviewing (Rollnick & Miller) Patient Activation Model/PAM Direct HCP notification - critical incidents Quarterly progress reports (Plan, HCP, & member) Website – information & progress tracking

17 Challenges Bad data from the health plan on Pts/members (information) Member unawareness of DM Company or its role (trust) Member motivation (multiple reasons) Info exchange: Plan – Member – HCP – DM Company Inconsistency of data (how prove success of DM?)

18 U.S. Health Care System – Insurance Grades and Report Cards (NCQA, URAC) Role of Levels of Prevention Costs of Chronic Diseases Disease Management (DM) – LifeMasters® Wrap Up

19 http://www.youtube.com/watch?v=-4LtYMNl4yw&feature=related http://www.lifemasters.com/index.asp http://www.healthways.com/


Download ppt "Chronic Disease Management in the U.S.A. Alicia Bengs."

Similar presentations


Ads by Google