Transcription

Integrated Health CareEarly Success Stories

OverviewThe IHC model, with its powerful data analytics component,allows employers to see the forest for the trees. Employerscan identify health patterns that can be addressed throughsystemic initiatives, such as health plan design changes,adjustments to health promotion strategies, and increasingresources dedicated to tackling a particular growinghealth problem.As integrated health care (IHC) continues its evolution frompioneering concept to accepted practice, the appeal of thiscare delivery model is increasingly evident.Industry research shows nearly one-third of employers withat least 10,000 employees have adopted some form ofintegrated care, and one in five with at least 750 employeesis in the process of doing so. An equal proportion in thelatter bracket (750 employees) either plans to introduceintegrated care in the future or is considering such a move.1Seeing “The Next Thing”“The more these programs develop, the more you’re ableto dig into the data and say, ‘What is this telling us?,’” saysKaren English, Partner and Senior Consultant with SpringConsulting Group, a multidisciplinary employee benefits andrisk management consultancy. “When programs are integrated, you are able to see the cumulative effect and identifythe next thing that can be done to make it even better.”Adoption among smaller companies is also on the rise,as favorable economics put integrated health care easilywithin reach of employers with as few as 100 employees.Integrated Health Care ResearchOne IHC system in particular—the single-carrier model—has demonstrated an exceptional capacity for maximizingintegration of health care delivery. This is due to the uniqueability of a unified enterprise to ensure the tightest links andcoordination possible between all involved coverages.This is the final briefing paper in a three-part series thatAnthem, Inc. commissioned:1.  Integrated Health Care—an emerging employeebenefits strategy to reduce costs and improve healthoutcomes.2.  The Integrated Health Care Journey—a guide foremployers implementing an IHC model for the first timeor for those already offering IHC and want to evaluatetheir program.The single-carrier IHC model is based on four broad coverage combinations through which employees enter thesystem: medical and pharmacy; medical and dental; medicaland vision; or medical and disability.3.  Integrated Health Care Early Success Stories—a summary of early industry reports of IHC success.Integrating PharmacyThe importance of integrating medical and pharmacybenefits is self-evident: Pharmacy is the most used of allhealth benefits and is used four times more than medicalbenefits.3 On average, 75% of doctor visits involve drugtherapy.4 Nearly two-thirds of employers report they havealready integrated their medical and pharmacy components.1To learn more and view the other two papers, please visitspecialtybenefits.info/ihc.Enhancing Health CareIHC is an innovative approach to managing and improvinghealth care by connecting typically stand-alone benefits,including medical, pharmacy, dental, vision, and disability.Financial protection benefits, such as life insurance, also canbe effectively woven into an IHC system.The proliferation of expensive specialty and biotechdrugs lends urgency to the need for the comprehensiveapproach the IHC model supports. Net spending onspecialty drugs constituted 310 billion in 2015, a 20%increase from 2014.5 Since specialty drugs may be covered under the pharmacy benefit or the medical benefit,an integrated approach offers line of sight into both fortrend/spend analyses and development of coordinatedmanagement strategies.Employer adoption of IHC systems is being driven bymultiple objectives, including (in order of prevalence): healthcost savings, improving employee health and wellness,encouraging employee engagement in health programs,employee retention, reducing employee absences, andboosting employee productivity.1 These related andoverlapping employer goals are increasingly being viewedfrom a population health perspective. Seen through that lens,health is understood not merely as a disease-free state, butalso as “the capacity of people to adapt to, respond to, orcontrol life’s challenges and changes.”2Robust, timely medical and pharmacy data/analyses areused in an IHC model to coordinate with health care providers.Doctors can be warned about gaps in patient care, such as:   Not taking medications as prescribed   Missing important medications as a part of their treatment   Opportunities to use lower cost medications   Being at risk for drug interactions2

How Integrated Health Care DrivesResults: Medical and PharmacyIntegrating DentalIt’s well known that vital medical information can begleaned from oral examinations, but the role dental careplays in population health is still underestimated. Accordingto the Academy of General Dentistry, 90% of the body’sdiseases first show signs and symptoms in the mouth.9Similarly, 120 medical conditions can be detected by anexamination of the mouth, throat, and neck—and earlierdetection can lead to earlier treatment,10 possibly reducingthe severity of the condition.One insurance carrier analyzed the results its clients haveachieved from integrating medical and pharmaceutical caredelivery systems.6 When comparing patient experienceswith integrated medical and pharmacy to those withcarve-out pharmacy benefits, it was discovered,among other things, that:   Identification of “care gaps” was 28% higher withIHC, and 26% more of those gaps were subsequentlyclosed within 12 months.How Integrated Health Care DrivesResults: Medical and Dental The hospitalization rate was 10% lower with IHC.In addition, certain medical conditions can be improvedwith good oral health. For example, if diabetic patientsdevelop periodontal disease, it can elevate their bloodsugar levels. Therefore, good oral health, which is bestachieved through regular professional cleaning, is key tocontrolling these patients’ diabetes and improving theiroverall health.   Medical costs for diabetic employees were reduced by7% with IHC, or 50 per plan member per month.   Employees with hypertension who had IHC had 14%fewer hospital stays and 6% lower medical costs,translating to medical cost savings of 38 per planmember per month.Integrating dental and medical plans represents a uniqueopportunity to co-manage diabetes and certain otherdiseases that benefit from good oral health. Researchshows that patients with certain medical conditions thattreat their periodontal disease have fewer hospitalizationsand lower medical costs:Another important finding was that patient compliance withprescription regimens, a vital driver of medical outcomes,was 37% higher with IHC.7How Integrated Health Care Works:The Patient Experience   Patients with diabetes who receive dental treatmentWhile visiting her doctor, Sarah learned she has diabetesand needs to take medication. When Sara was later admitted to the hospital with unstable blood sugar levels,her insurance company quickly relayed the informationto a care manager. Her nurse care manager contactedSarah to talk about her condition and the importance ofproper nutrition, exercise, and taking her medication regularly.for periodontal disease have 39% fewer hospital admissions and 40% lower medical costs.   Patients with coronary artery disease who receivedental treatment for periodontal disease experience28% fewer hospital admissions and 10% lowermedical costs.With the help of her nurse, plus her insurer’s coordinationwith her doctor, medication reminders, messages aboutgaps in care, and free blood glucose monitoring, Sarah isnow able to focus on maintaining a healthier lifestyle andsticking to her medication therapy. This will save her moneyon medicine and test strips.   Patients with rheumatoid arthritis who receivedental treatment for their periodontal diseasehave 4% fewer hospital admissions and 6%lower medical costs.11Furthermore, single-carrier models take IHC a step furtherby employing care managers to ensure that the necessarylinks are made and care is provided.12 Because good oralhealth is so important for in the management of certainhealth conditions, care managers automatically enrollpatients with certain medical conditions in an extra dentalcleaning or periodontal maintenance procedure each year.This is just one way the single-carrier IHC benefit designsupports the goal of having employees and their dependents receive comprehensive, coordinated care.Overall, data from one insurer shows plan members withdiabetes who have integrated medical and pharmacybenefits had 59% better medication adherence, 7% fewerhospitalizations and 7% lower medical costs overall. 83

How Integrated Health Care Works:The Patient ExperienceHow Integrated Health Care DrivesResults: Medical and VisionNatalie has diabetes and is enrolled through her insurancecarrier in a diabetes management program.In an IHC system, claims data from both realms of carecomplement direct observations of providers in patientvisits. The combination of the two allows medical andvision experts to connect the dots to find possible gapsin care, across both adult and pediatric care plans.This results in:The diabetes management program provided the extrasupport that Natalie needed to manage her condition. Shelearned how to make lifestyle changes to improve herhealth. Her nurse care manager also automatically enrolledher in an additional dental cleaning to help Natalie maintaingood oral health.   Lower medical costs. Patients with diabetes who don’tuse a comprehensive vision benefit experience 20%higher medical costs, followed by cardiovasculardisease at 15%, and hypertension at 7%.14Research indicates these changes might reduce thenumber of hospital visits Natalie will make by 39%, lowerher potential medical costs by 40%,11 and likely decreasethe number of lost work hours she will experience.   Greater awareness. Three-fourths of people who learnthey are pre-diabetic take steps such as increasingphysical activity.15Integrating VisionHow Integrated Health Care Works:The Patient ExperienceOptometrists and ophthalmologists can detect early signsof some conditions and diseases by examining a patient’socular blood vessels and retina. For example, they can discern whether a patient has hypertension or is developingdiabetes, high cholesterol, heart disease, or other problems.After experiencing blurry vision, Robert visited his optometrist, who determined the problem was likely a result of anallergy medication.This means employers have a tremendous opportunity toimprove employee health by integrating vision and medicalcare. Research shows employees who have vision coverage are three times more likely to get an eye exam thanan annual physical.13However, during the exam, the doctor also identified clinicalsigns of diabetes. This information was captured through theclaims process, and Robert was automatically enrolled in adiabetes management program. The program helped Robertmake lifestyle changes to improve his health and reducefuture medical costs up to 20%.14Many carriers have built a “one-way” connection betweenvision and medical plans, meaning when an eye doctordetects a medical issue through a routine exam, the patientis referred to a primary care provider and a medical caremanagement team. However, very few carriers have a“two-way” connection that allows the eye doctor and PCPto share relevant patient data in a HIPAA-compliant andsecure manner.Research indicates that pre-diabetic patients takingpreventative measures, like losing weight and reducingcaloric intake, can reduce their risk of developing thedisease by up to 58%.15Integrating DisabilityAccording to the Council for Disability Awareness, 90% ofdisabilities are caused by illnesses rather than accidents.16This counter-intuitive statistic is supported by researchexperience that one-in-three claims are filed prior to theanticipated period of absence and another 40% of claimsare received before the end of the first week of anemployees’ absence.17An eye doctor operating within a two-way IHC model canview relevant patient health histories, diagnoses,lab results, and prescriptions for a complete health picture.Similarly, a PCP operating within a two-way IHC modelmay receive an alert when a medical issue has beendetected for one of their patients through a routinevision exam.These facts highlight the opportunity afforded by a single-carrier IHC arrangement to mitigate the severity of thedisabling condition and reduce the period of absence fromwork. That’s significant, since it is estimated that the costof employee absenteeism is four times that of employeehealth benefit expenses.184

How Integrated Health Care Works:The Patient ExperienceA tightly integrated plan linking disability and medical benefitsallows for early identification of an upcoming disability,thereby alerting care managers to discuss with employersand employees appropriate stay-at-work strategies, including workplace and job modification, as well as acceleratedreturn-to-work opportunities. It also effectively coordinateswith protected time off, such as family medical leave underthe FMLA or other state-mandated programs.Twenty-three weeks into her pregnancy, Daphne experienced complications and was told there was a high riskthat she would deliver prematurely. Her physician recommended bed rest until the baby was born.When Daphne contacted her insurer to initiate disabilityand FMLA claims, she was automatically referred to theinsurer’s multifaceted maternity care program. A speciallytrained maternity care nurse worked with Daphne toeducate her about proper pre-natal care and provide support through the remainder of the pregnancy. This helpedDaphne carry her daughter to full term, thereby avoidinga costly neonatal intensive care unit admission. And shereturned to work on schedule.How Integrated Health Care DrivesResults: Medical and DisabilityAccording to research, employees experience lower medical costs when disability benefits are coordinated with amedical nurse care manager who is supported by insightsfrom data analytics, as occurs in a single-carrier integratedplan. The research17 found:Data shows that employees with integrated disability andmedical care on average use seven fewer disability daysand have 25% lower medical costs.17   Medical costs associated with a disability claim were 8,000 lower for members who engaged with a medical nurse care manager following referral from theirdisability case manager.   Plan sponsors experienced a 9% savingsin year-over-year disability costs.   24% of employees returned to work early,increasing their overall productivity.SourceMedia Research, Integrated Health Care Buyer Journey Study, November 2015Frankish, CJ et al. “Health Impact Assessment as a Tool for Population Health Promotion and Public Policy”Vancouver: Institute of Health Promotion Research, University of British Columbia, 1996.3 Retail Prescription Drugs Filled at Pharmacies (Annual per Capita), kff.org; Ambulatory Care, Use and Physician Office Visits, US Centers for Disease Controland ian-visits.htm.4 Centers for Disease Control & Prevention website, National Ambulatory Medical Care Survey: 2010 Summary Tables (April 29, 2015):www.cdc.gov/nchs/data/ahcd/namcs summary/2010 namcs web tables.pdf5Medicines Use and Spending in the US: A Review of 2015 and Outlook to 2020, IMS Institute for Healthcare Informatics, April 2016.6 Anthem Inc. affiliated companies’ 2014 Study: Pharmacy Benefit & Clinical Program Integration; Performance Guarantee Evaluation(These results do not represent a guarantee of outcomes; group-specific results/cost savings will vary.)7 Anthem Inc. affiliated companies’ July 2015-June 2016 Medication Review (These results do not represent a guarantee of outcomes;group-specific results/cost savings will vary.)8 Anthem Inc. affiliated companies’ 2014 Medical and Pharmacy Integration Analysis. Diabetes medication adherence data from “Impact of Integrated Pharmacyand Medical Benefits in a Chronic Disease Management Program,” Anthem Inc. affiliated companies’ Pharmacy Solutions clinical poster, March, 2017.9Academy of General Dentistry Know Your Teeth website: Warning Signs in the Mouth Can Save Lives. (Rev. January 2012)10Oral Diagnosis, Oral Medicine and Treatment Planning, 199411American Journal of Preventive Medicine’s Impact of Periodontal Therapy on General Health Study, June 201412 Anthem Inc. affiliated companies’ integrated dental and medical plans proactively identify members with certain conditions, including pregnancy, diabetes, heartconditions, organ or bone marrow transplant, cancer (any type) treated with chemotherapy, and head or neck cancer treated with chemotherapy and/or radiation therapy.13Human Capital Management Services (HCMS) study on behalf of VSP, 201014American Optometrists Association (AOA), Safeway, Inc.15 Morbidity and Mortality Weekly Report, Nov 7, 2008; Self-reported prediabetes and risk reduction activities; United States, 2006;and American Diabetes Association, Pre-Diabetes FAQs, 2009.16 Council for Disability Awareness, 2016 (includes pregnancy)17 Journal of Occupational and Environmental Medicine, July 200718 Anthem Inc. affiliated companies’ Productivity Solutions Quantifying Value Study, 201512 5

Recommendationsthe sharing of data among multiple providers. This may appeal to employers that want to avoid putting “all their eggsin one basket,” English says. At the same time, she adds,there are challenges associated with the multiple-vendormodel, including “knowing who’s doing what and havingpatients receiving, and many times paying for, redundant care.”The medical, pharmacy, dental, vision, and disabilitycomponents of a single-carrier IHC model described inthis white paper are not the end of the story. Behavioralhealth, life insurance with advance death benefit riders,and even concurrent management of employee FMLA andother leaves are additional elements that—in an integratedsystem—result in a whole greater than the sum of its parts.As employers move forward toward greater integration oftheir health-related benefit offerings, they will need toassess the degree to which the promise of integratedhealth care can be delivered concretely to their organizations, and whether the cost is commensurate with thevalue proposition.Research and anecdotal illustrations reveal a powerfulcase for the IHC delivery model. Integration is a relativeconcept, however, and some health care delivery modelsand health care organizations offer more than others.Employers should educate themselves on the differencesamong plans in order to achieve maximum benefits.Health insurance is a dynamic environment, and the race ison to rapidly improve on yesterday’s foundation. ObservesEnglish: “The longer these models are around, the greaterimpact they are able to make, not only for employers, butfor employees and their families as well.” Integrated healthcare systems can save money, improve health and productivity, enhance population health program outcomes—andmost importantly, make a difference in people’s lives.For employers, “being able to offer multiple coveragesunder one roof and having care management at the centercan reach across the entire benefit experience,” notesSpring Consulting’s Karen English. “It can start with prevention and carry through to management in a seamlessand effective way.”An alternative approach to IHC involves using specializedthird-party entities to coordinate health service delivery andSource: Anthem Inc., December 2016 Employee Benefits Survey6

IHC is an innovative approach to managing and improving health care by connecting typically stand-alone benefits, including medical, pharmacy, dental, vision, and disability. . therapy.4 Nearly two-thirds of employer