CMS (Centers for Medicaid and Medicare) this week announced its picks for companies to participate in 10 experimental programs to manage care of patients with chronic conditions. The hope is that keeping these patients healthier will improve their lives—and save the government money.
Forty-three percent of Medicare spending goes to the 14 percent of beneficiaries with congestive heart disease, while 32 percent goes to the 18 percent of beneficiaries with diabetes, according to CMS, which did not describe the amount of overlap between these groups of patients.
The CCIPs (chronic care improvement programs) are expected to keep patients out of emergency rooms and hospitals by keeping them healthier, a task that requires sophisticated tracking of patient information.
The CCIP companies already work with patients to help them manage aspects of their own health care, such as monitoring glucose or weight levels; they also may provide behavioral counseling or work with a patients physician. Nurses often talk regularly with patients by phone to provide encouragement, guidance and education.
Such services have been credited with keeping down health care costs by preventing medical complications such as heart attacks. But a controversial study by the Congressional Budget Office concluded that such programs do not curb costs.
The CCIPs will evaluate potential savings through randomized, controlled studies. In geographical areas with high rates of chronic conditions, CMS beneficiaries eligible for a disease management program will be invited at random to participate. Health benefits and medical expenditures in participating and nonparticipating patients will be compared. The 10 CMS pilot programs are scheduled to last three years.
In an unusual arrangement, companies will not be paid for providing disease management services unless they show a net savings of 5 percent compared with a control group in the first pilot phase of the program. However, the best-performing companies will then be eligible to take on segments of the larger Medicare population in the second phase. According to the CMS Web site, more than 38 million people were enrolled in Medicare in 2003.
Using information technology well is essential to influencing patients, said Scott Kozicki, chief technology officer at America Healthways.
"Its all about processing that data and targeting people with the right message at the right time. Were kind of a technology company masquerading as a health care company," Kozicki said. "We know a lot about each individual and we customize interactions for each person" to encourage healthy behaviors.
He said his company is confident that it can both save money and serve a large Medicare population.
The company already manages more than 1.3 million individuals, many in diabetes and congestive heart failure, and has expanded rapidly, partly due to a good choice of partners. In 2001, American Healthways decided it wanted to develop a data warehouse to hold the clinical data collected by call-center nurses.
Bert Chaffin, senior director of applications, said American Healthways first considered end-to-end applications, but the project bogged down. When they considered "best of breed" solutions, they happened on Informatica, eventually purchasing a license for the data integration platform in September 2001 to run it on a 32-bit Windows 2000 platform.
This spring, American Healthways migrated to a 64-bit release of PowerCenter. Kozicki said hes been happy with the results. "We were seeing some jobs that were taking days that were finishing in a few hours."
One advantage is that InformaticaPowerCenter has been able to keep up with data demands that have doubled every year. "Our implementation timelines are very aggressive," Chaffin said. "Weve got to process their data into our application very quickly. From a technology side, weve seen almost unlimited scalability in the product."
Kozicki and Chaffin said the Informatica PowerCenter can be used in ways they hadnt intended, such as claims processing and getting data ready for predictive modeling.
Kozicki said he anticipates that it will be particularly useful for using CMS data that will be packaged differently than those from a health plan and also will be less accurate in terms of demographic information that would otherwise be supplied by an employer.
Other companies selected by CMS include: Aetna Health Management in Chicago; Health Dialog Services Corp. in Pennsylvania; Humana Inc. in central Florida; LifeMasters Supported SelfCare Inc. in Oklahoma; McKesson Health Solutions in Mississippi; Visiting Nurse Service of New York in partnership with United HealthCare Services Inc.-Evercare in Queens and Brooklyn in New York; and XLHealth in Tennessee.
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