Insurers Want The Calls To Go Through

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Health-care Overhaul May Threaten Popular Disease Management Programs

Venante Kotey is a stay-at-home mother in Dumfries. Bridget Hamilton-Roberts is a nurse more than 500 miles away in Atlanta. They’ve never met. But over the past year and a half, Hamilton-Roberts has become critical to Kotey’s health —
all through conversations over the telephone.

The two are part of an innovative disease management program that links patients with caregivers across the country. Every week — and sometimes every day — the nurse calls the mom with tips on how to monitor her Type 2 diabetes with blood sugar and lipid tests. She has enrolled Kotey, 35, in free lessons on how to give herself insulin, persuaded her doctor to provide a faster-acting version, and found her a psychiatrist to treat her depression. Hamilton-Roberts has also become a trusted confidante, said Kotey, a person who "really gives me the force to go on… I love Bridget; she is like family."

These phone-based programs have sparked debate, with critics claiming there is little evidence that they actually work, and proponents — including many insurance companies — lauding them as precisely the sort of prevention-oriented
approach needed to fix the health-care system. That debate has gained new salience because of a key requirement of the sweeping health-care overhaul enacted by Congress this year.

Starting next year, most health insurance plans will be required to spend 80 to 85 percent of the premiums they collect on medical claims or other activities that improve members’ health. Profits and other costs such as administrative expenses must account for no more than 15 to 20 percent. The Obama administration is drafting regulations that will determine which, if any, disease management programs insurers will be able to count as improving members’ health. Consumer advocates argue that only programs whose effectiveness has been scientifically proven should be included. But insurers warn that if the rules are so strict that most of their disease management programs don’t qualify, they will be forced to curtail or even drop them.

"We’re talking about turning back the clock on really innovative efforts," said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, an industry group.

A matter of trust

Increasingly popular since the early 2000s, disease management has blossomed into a more than $2.4 billion industry, with programs included in practically all plans offered by large employers, in nearly half of group plans purchased by
small businesses, and in many state Medicaid programs, according to the human resources consulting company Mercer and the Disease Management Purchasing Consortium.

Details of the programs vary as widely as the range of illnesses and conditions addressed. Some insurers administer them in-house, but more often the service is contracted out to specialized companies. Hamilton-Roberts’s employer, OptumHealth, is a subsidiary of UnitedHealth Group and provides disease management for Delta Air Lines, where Kotey’s husband works. For programs run by insurance plans, the care manager — often a nurse — is usually at a remote location and communicates through phone calls, e-mails or texts.

The 80-85 requirement does not apply to self-insured plans, which are typically provided by large employers. Using a company hired to administer the plan, the employer collects premiums from its employees and pays claims directly, rather
than purchasing a group plan on behalf of the employees.

Even supporters of disease management programs worry that the rules being drafted will prove too loose, prompting insurers to lump in all sorts of programs that are at best unproven and at worst actually administrative in nature.

"You cannot trust the insurance industry to police itself. You have to watch them like a hawk," said Judy Dugan, research director of the advocacy group Consumer Watchdog.

At a minimum, said Dugan, disease management programs run by insurers should be accredited by an independent organization. The most prominent, the National Committee for Quality Assurance, which has approved Kotey’s program, offers accreditation for those covering only five chronic illnesses: diabetes, asthma, heart failure, chronic obstructive pulmonary disease and ischemic vascular disease. Dugan and others say the government should also demand that insurers provide evidence that a disease management program they want to count as a health improvement activity actually delivers on that promise. Whether the programs can do so is a matter of dispute.

Industry representatives oppose mandatory testing of individual programs as impractical given the sheer number of programs, the small population each serves and the continual changes that are made to them. But they point to a raft of
studies suggesting that programs can produce short-run benefits such as lowering blood pressure and blood glucose levels.

However, most of those studies fail to use the most rigorous scientific methods, said Randall Brown, director of health research at Mathematica, a firm that has analyzed such programs for the government.

Soeren Mattke, a senior scientist at the Rand Corp., who has reviewed the limited range of independent scientific studies on the subject, said that there is "very little evidence" that any short-run benefits produced by disease management programs translate into a reduction in the kind of complications that require hospitalizations or emergency room visits. Brown said that to understand the drawbacks of disease management, it helps to look at what he has found does often work: "care management" initiatives, run not by the insurance company but directly out of a doctor’s office, whose coordinating nurses meet face-to-face with both patients and their physicians.

Patients may be more likely to be responsive to someone introduced to them in person by their doctor, Brown said. Doctors may be more likely to consult and coordinate with a nurse they know well rather than a "disembodied voice" calling from an insurance company. "That in-person engagement can make all the difference in the world."

‘Don’t do anything’

Both the possibilities and the limitations of the phone-based alternative offered by OptumHealth were evident during nurse Hamilton-Roberts’s recent call to Kotey.

Kotey was barefoot and in curlers, bouncing a ball to her 4-year-old son in the driveway of her suburban townhouse, when the phone rang.

A former secretary who moved to the United States from Haiti six ago years and still struggles with English, Kotey said that when her doctor first diagnosed her diabetes, she was so overwhelmed she failed to comprehend many of the details. But on this afternoon Kotey rattled off answers to the nurse’s queries with seasoned ease.

"Have you been able to check your blood pressure?" asked Hamilton-Roberts.

"135 over 75," replied Kotey.

"Do you know what your latest hemoglobin A1C value was?"

"8.2" was the answer. Her A1C level, which measures a diabetic patient’s average blood glucose levels over a prolonged period of time, had dropped one percentage point from two years ago, though it was still above the recommended level of 7 percent.

"We’re very attuned to what’s available to the patient," said Hamilton-Roberts. "The physician might have been thinking, ‘Oh, I know this patient has financial problems and I know how much these [education] programs cost.’ Well, the physician doesn’t know that the patient has benefits that will cover that."

Still, for all her progress, Kotey’s blood pressure and blood sugar levels remain stubbornly high. Although she has lost 14 pounds, with 196 pounds on her petite frame, she still has a way to go to reach a healthy weight.

And there are times when personal rapport can’t help Hamilton-Rogers overcome the challenge of communicating by phone.

"I want to ask if I can drink ah-spee-REEN," said Kotey in her heavy accent at one point, reading the label off a bottle of aspirin pills. "They say he’s good for blood clots."

"Ah-SPEE-rion?" the nurse responded quizzically. "I’m not familiar with that… Don’t do anything as of yet… These things have to be cleared by your doctor first."

"Now, what about that aspirin?" Hamilton-Rogers continued, prompting a confused look from her patient. "Are you taking your baby aspirin every day?"

Consumer Watchdog
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