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Consumer-directed health care and case management: Part 2
Consumer-Directed Health Care and Case Management:
Part 2 Amit Gupta, MD
P
reviously, we reviewed the three basic plan designs in consumerdirected health care (CDH):
• Health savings accounts (HSAs): Consumer-owned bank accounts that provide tax benefits on funds contributed by individuals and/or employers. Once contributed, the money in this account is owned by the consumer and is fully portable, with no rollover caps from year to year on unused funds. These accounts may cover prevention for each enrolled member. • Health reimbursement arrangements (HRAs): employer funds made available to cover an employee’s qualified expenses through a carrier. HRAs allow 100% prevention coverage to each enrolled member and permit money to be rolled over from year to year, with rollover caps as desired by the employer and health plan. HRAs are not portable, but the law does permit access to the funds beyond employment, as long as the funds reside with the employer. • Flexible spending accounts (FSAs): funds deducted tax-free from employee salaries to cover specific expenses. These are “use it or lose it funds” that expire at the end of the year. September/October 2005
TCM 57
Plan designs in a CDH offering typically are paired with high deductible health plan coverage that incorporates catastrophic coverage once the deductible is met. How can case managers work with CDH? This coverage relies on patients making informed decisions about health care. To help with these choices, many CDH plans provide decision support tools, disease management (DM) tools, and, in some cases, employee incentives and rewards programs (much like credit card reward points) to help control subscriber spending, increase preventive care, improve compliance, and otherwise increase healthy behaviors. While these instruments can assist patients with decision making, help provide the appropriate incentives for them to adopt healthy behaviors, or promote compliance to chronic DM programs, case managers need to be closely tied to these tools to monitor and intervene as needed. In the short and the long term, these tools can lead to better coordination of patient care, fewer unnecessary expenses, and reduced health care costs. What Are Some of the Tools Found in CDH Offerings? Personalized decision support tools These tools can help patients make intelligent decisions about their health. These tools are relevant to both healthy members and those who are chronically ill or who have complicated health conditions. For healthier members, the tools can maximize HRA or HSA savings by highlighting the alternatives available to unnecessary and expensive treatment options. Members can elect their own course of action based on the knowledge provided. For those who are chronically ill or who have complicated health conditions, these tools can help in the selection of higher-quality providers and, hopefully, can produce better long-term outcomes, while at the same time allowing patients to lower total costs by comparing provider, procedure, and drug prices. For example, a chronic disease patient might change his or her drug from a brand name to a generic drug to save money in his or her account. It is important that, when these tools are used by TCM 58
September/October 2005
A feature that may be offered in a CDH plan, reminder tools can send notes to a client s e-mail or can telephone to let him know it is time to take his medicine. patients with chronic disease, case managers have means to monitor such selections to ensure that the generic alternative selected is providing adequate control of the chronic disease. If CDH plans lead many patients to select cheaper alternatives at the cost of jeopardizing desired outcomes or control of a condition, costs can increase in the long term. Case managers, by working closely with the tools available to patients, can help to avoid the pitfalls associated with the push to select more cost-effective treatment options. Online health-risk appraisal tools Online health-risk appraisal tools can be used by patients to create personal health-risk profiles, along with a report card on suggested areas for improvement. These tools can help assess the patient’s individual health care needs, both present and future, and estimate future costs. By using these tools, specific risk factor management programs can be created, funded from an account carved out for DM needs, with the appropriate positive incentives for patients to perform DM activities defined under such programs. When a DM program with an associated incentive structure is instituted, it is important for a case manager to mon-itor the patient’s progress to ensure compliance and to intervene if a patient is noncompliant. Online personal health records Online personal health records are another tool offered by health management companies working in the CDH space. These records allow members to maintain their own personal health history and to share this information with any nurses, doctors, or physicians they visit. These tools can help to better coordinate patient care among multiple providers, reduce redundancy in care, and help prevent harmful drug interactions. CDH can make personal health records portable, long term, and contin-
uous, allowing case managers to have better data on the efficacy of chronic DM programs, health utilization behavior, outcomes, and on the role of incentives in affecting healthy behaviors. Cost comparison tools Cost comparison tools compare hospital and doctor costs and measure different statistics, such as the number of times a physician has performed a procedure, and also are available as part of many CDH offerings. Such tools can help patients and their case managers increase their price consciousness and estimate cost savings, enabling the push toward greater consumerism. Case managers involved with the care of patients may frequently be asked to comment on hospital, provider, and drug alternatives, therefore, they will need to have access to and training in these tools to provide appropriate support. Tools that link claims to information The market is beginning to develop new ways for clients to actually link their claims to information tools. For example, if a pregnant client submits a claim for an ultrasound, it can be linked to a specific service code that can trigger an email or mailing with pregnancy-related articles or information. While it is easier to link claims data to delivery of personalized information or messaging to patients, ideally, CDH will require such information delivery to occur before a claim for a service is filed. By doing so, a patient will be more informed about health care services at the time he or she receives the care to make the most costeffective decisions. Maintenance or prevention accounts Some CDH accounts can be structured to act as tools. Accounts specifically for maintenance (e.g., purchasing insulin for diabetics) or prevention (e.g., physicals) may be offered as part of the CDH plan. Setting up specific accounts, such
as prevention accounts that do not rollover and must be used before the year’s end, can help influence patients to use nonrollover account dollars for preventive services and to take the best care of themselves possible. Case managers can be engaged to monitor the use of DM accounts. For example, if a patient does not fill his prescription for a needed maintenance drug, the case manager may intervene and call that person to remind him. CDH tools and technologies will need to be able to inform case managers about prevention and compliance issues on a timely basis for them to intervene. Reminder tools A feature that may be offered in a CDH plan, reminder tools can send notes to a client’s e-mail or can telephone to let him know it is time to take his medicine. Reminder tools often are bundled into maintenance accounts. In addition, incentives can be built on top of the reminders. For example, a person might be reminded
to take a medication. When they do so, the messaging device captures an input that auto-allocates points into a member ’s reward program. Member rewards and incentives Subscribers to CDH plans can be encouraged to take advantage of decision support tools through member rewards and incentives. These rewards are customizable and provide incentives to those who change their behavior and proactively manage their health. These incentives further increase overall compliance to DM programs by rewarding patients for healthy behaviors. Reward plans can be structured in various ways (such as reward points for redemption at a merchant or partners selected by the health plan/employer, or the provision of additional account dollars) and can be used to steer patients toward leading healthier lives, such as participating in smoking cessation programs. Conclusion Services like online health-risk appraisal tools and drug-cost comparison tools
allow patients to be better informed about important information, such as new medical techniques, costs for procedures and prescription drugs, and industry trends. Informed patients naturally turn to case managers for additional advice, and, therefore, case managers also need to have access to such tools. Being more informed can help case managers support their patients with the best recommendations possible. By incorporating decision support tools and rewards or incentives into CDH programs, both short- and long-term health care costs can be reduced. It is important for case managers to work with their health plans to help plan the design of CDH offerings and to customize and mold CDH into a product that is useful for them. ❏ Amit Gupta, MD, is president and COO of CareGain in East Windsor, N.J. Reprint orders: E-mail authorsupport@ elsevier.com or phone (toll-free) 1-888-8347287; reprint no. YMCM 318 doi:10.1016/j.casemgr.2005.07.010
September/October 2005
TCM 59
Part 2 Amit Gupta, MD
P
reviously, we reviewed the three basic plan designs in consumerdirected health care (CDH):
• Health savings accounts (HSAs): Consumer-owned bank accounts that provide tax benefits on funds contributed by individuals and/or employers. Once contributed, the money in this account is owned by the consumer and is fully portable, with no rollover caps from year to year on unused funds. These accounts may cover prevention for each enrolled member. • Health reimbursement arrangements (HRAs): employer funds made available to cover an employee’s qualified expenses through a carrier. HRAs allow 100% prevention coverage to each enrolled member and permit money to be rolled over from year to year, with rollover caps as desired by the employer and health plan. HRAs are not portable, but the law does permit access to the funds beyond employment, as long as the funds reside with the employer. • Flexible spending accounts (FSAs): funds deducted tax-free from employee salaries to cover specific expenses. These are “use it or lose it funds” that expire at the end of the year. September/October 2005
TCM 57
Plan designs in a CDH offering typically are paired with high deductible health plan coverage that incorporates catastrophic coverage once the deductible is met. How can case managers work with CDH? This coverage relies on patients making informed decisions about health care. To help with these choices, many CDH plans provide decision support tools, disease management (DM) tools, and, in some cases, employee incentives and rewards programs (much like credit card reward points) to help control subscriber spending, increase preventive care, improve compliance, and otherwise increase healthy behaviors. While these instruments can assist patients with decision making, help provide the appropriate incentives for them to adopt healthy behaviors, or promote compliance to chronic DM programs, case managers need to be closely tied to these tools to monitor and intervene as needed. In the short and the long term, these tools can lead to better coordination of patient care, fewer unnecessary expenses, and reduced health care costs. What Are Some of the Tools Found in CDH Offerings? Personalized decision support tools These tools can help patients make intelligent decisions about their health. These tools are relevant to both healthy members and those who are chronically ill or who have complicated health conditions. For healthier members, the tools can maximize HRA or HSA savings by highlighting the alternatives available to unnecessary and expensive treatment options. Members can elect their own course of action based on the knowledge provided. For those who are chronically ill or who have complicated health conditions, these tools can help in the selection of higher-quality providers and, hopefully, can produce better long-term outcomes, while at the same time allowing patients to lower total costs by comparing provider, procedure, and drug prices. For example, a chronic disease patient might change his or her drug from a brand name to a generic drug to save money in his or her account. It is important that, when these tools are used by TCM 58
September/October 2005
A feature that may be offered in a CDH plan, reminder tools can send notes to a client s e-mail or can telephone to let him know it is time to take his medicine. patients with chronic disease, case managers have means to monitor such selections to ensure that the generic alternative selected is providing adequate control of the chronic disease. If CDH plans lead many patients to select cheaper alternatives at the cost of jeopardizing desired outcomes or control of a condition, costs can increase in the long term. Case managers, by working closely with the tools available to patients, can help to avoid the pitfalls associated with the push to select more cost-effective treatment options. Online health-risk appraisal tools Online health-risk appraisal tools can be used by patients to create personal health-risk profiles, along with a report card on suggested areas for improvement. These tools can help assess the patient’s individual health care needs, both present and future, and estimate future costs. By using these tools, specific risk factor management programs can be created, funded from an account carved out for DM needs, with the appropriate positive incentives for patients to perform DM activities defined under such programs. When a DM program with an associated incentive structure is instituted, it is important for a case manager to mon-itor the patient’s progress to ensure compliance and to intervene if a patient is noncompliant. Online personal health records Online personal health records are another tool offered by health management companies working in the CDH space. These records allow members to maintain their own personal health history and to share this information with any nurses, doctors, or physicians they visit. These tools can help to better coordinate patient care among multiple providers, reduce redundancy in care, and help prevent harmful drug interactions. CDH can make personal health records portable, long term, and contin-
uous, allowing case managers to have better data on the efficacy of chronic DM programs, health utilization behavior, outcomes, and on the role of incentives in affecting healthy behaviors. Cost comparison tools Cost comparison tools compare hospital and doctor costs and measure different statistics, such as the number of times a physician has performed a procedure, and also are available as part of many CDH offerings. Such tools can help patients and their case managers increase their price consciousness and estimate cost savings, enabling the push toward greater consumerism. Case managers involved with the care of patients may frequently be asked to comment on hospital, provider, and drug alternatives, therefore, they will need to have access to and training in these tools to provide appropriate support. Tools that link claims to information The market is beginning to develop new ways for clients to actually link their claims to information tools. For example, if a pregnant client submits a claim for an ultrasound, it can be linked to a specific service code that can trigger an email or mailing with pregnancy-related articles or information. While it is easier to link claims data to delivery of personalized information or messaging to patients, ideally, CDH will require such information delivery to occur before a claim for a service is filed. By doing so, a patient will be more informed about health care services at the time he or she receives the care to make the most costeffective decisions. Maintenance or prevention accounts Some CDH accounts can be structured to act as tools. Accounts specifically for maintenance (e.g., purchasing insulin for diabetics) or prevention (e.g., physicals) may be offered as part of the CDH plan. Setting up specific accounts, such
as prevention accounts that do not rollover and must be used before the year’s end, can help influence patients to use nonrollover account dollars for preventive services and to take the best care of themselves possible. Case managers can be engaged to monitor the use of DM accounts. For example, if a patient does not fill his prescription for a needed maintenance drug, the case manager may intervene and call that person to remind him. CDH tools and technologies will need to be able to inform case managers about prevention and compliance issues on a timely basis for them to intervene. Reminder tools A feature that may be offered in a CDH plan, reminder tools can send notes to a client’s e-mail or can telephone to let him know it is time to take his medicine. Reminder tools often are bundled into maintenance accounts. In addition, incentives can be built on top of the reminders. For example, a person might be reminded
to take a medication. When they do so, the messaging device captures an input that auto-allocates points into a member ’s reward program. Member rewards and incentives Subscribers to CDH plans can be encouraged to take advantage of decision support tools through member rewards and incentives. These rewards are customizable and provide incentives to those who change their behavior and proactively manage their health. These incentives further increase overall compliance to DM programs by rewarding patients for healthy behaviors. Reward plans can be structured in various ways (such as reward points for redemption at a merchant or partners selected by the health plan/employer, or the provision of additional account dollars) and can be used to steer patients toward leading healthier lives, such as participating in smoking cessation programs. Conclusion Services like online health-risk appraisal tools and drug-cost comparison tools
allow patients to be better informed about important information, such as new medical techniques, costs for procedures and prescription drugs, and industry trends. Informed patients naturally turn to case managers for additional advice, and, therefore, case managers also need to have access to such tools. Being more informed can help case managers support their patients with the best recommendations possible. By incorporating decision support tools and rewards or incentives into CDH programs, both short- and long-term health care costs can be reduced. It is important for case managers to work with their health plans to help plan the design of CDH offerings and to customize and mold CDH into a product that is useful for them. ❏ Amit Gupta, MD, is president and COO of CareGain in East Windsor, N.J. Reprint orders: E-mail authorsupport@ elsevier.com or phone (toll-free) 1-888-8347287; reprint no. YMCM 318 doi:10.1016/j.casemgr.2005.07.010
September/October 2005
TCM 59