Innovations in Preventing and Managing Chronic Conditions: What's Working in the Real World?

Originally published by the Center for Studying Health System Change (HSC). HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Innovations in Preventing and Managing Chronic Conditions: What's Working in the Real World?

Issue Brief No. 132 — June 2010

Alwyn Cassil

The prevalence of chronic disease and obesity in the United States continued to climb through the 2000s, placing growing pressure on both health outcomes and health care budgets. HSC's Health Tracking Household Survey showed that 39 percent of working-age Americans had at least one chronic condition by 2007, up from 34 percent in 2001. Obesity rates among working-age adults rose from 23 percent in 2003 to 29 percent in 2007. These trends were driving health care costs upward and highlighting the U.S. health system's persistent focus on treating acute episodes of illness rather than helping people avoid getting sick in the first place.

In April 2009, HSC convened a conference exploring real-world approaches to preventing chronic disease and improving care for people already living with chronic conditions. This Issue Brief by Alwyn Cassil summarized the conference proceedings and the strategies that panelists described.

Health as a Business Strategy

D. W. Edington, professor and director of the University of Michigan's Health Management Research Center, argued that the cost of sickness in America posed a direct threat to economic competitiveness. U.S. businesses burdened by high health care costs struggled to compete globally, yet the health care system was oriented almost entirely around treating disease rather than promoting health. Most employers waited for their workers to get sick and then paid the bills, rather than investing in keeping healthy employees healthy.

Edington presented data showing that high-risk employees contributed disproportionately not only to health care costs but also to absenteeism, disability, and other indirect expenses. He maintained that individual behavior change programs, while a reasonable concept, were insufficient on their own. Companies needed to integrate health improvement into their corporate culture, starting with visible leadership from the CEO and top management, and extending into the wider community. Without community-level change, he argued, gains made in the workplace would erode once workers returned to unhealthy environments.

Community-Wide Health Improvement: Allegiance Health

Amy Schultz, director of prevention and community health at Allegiance Health in Jackson, Michigan, described how a community-wide health initiative grew out of a local crisis. In 1999, southeast Michigan employers faced 40 percent increases in health insurance premiums. Allegiance Health recognized that unchecked cost growth would push more residents into uninsurance, worsening community health and driving costs still higher. Working with Edington's center at the University of Michigan, the hospital system developed the "It's Your Life" program.

Allegiance began with its own employees, who despite being health care workers had above-average health risk profiles. When the organization initially tracked its workforce, about 70 percent were low-cost, but by the following year that had declined to 53 percent, demonstrating a deteriorating trend. The program used a health coaching model offering each employee one-on-one assistance to set goals, identify barriers to change, and track progress. Initially, participating employees received a $200 credit toward their health insurance, but Allegiance found that premium reductions were not visible enough to motivate participation. The incentive was switched to gift cards, and later a premium differential was added: nonparticipating employees paid an additional 20 percent of the employee-only premium, about $1,200 annually. Spouses covered by the plan also had to participate. By the time of the conference, about 95 percent of the eligible population was enrolled.

By 2008, the proportion of low-risk employees at Allegiance had grown from 48 percent to 63 percent, reversing the downward trend and demonstrating that the program was producing measurable cultural change.

Community Care of North Carolina: Breaking Down Silos

L. Allen Dobson Jr., former North Carolina Medicaid director and chairman of North Carolina Community Care Networks, described how the state restructured Medicaid care delivery through community-based networks of primary care providers. When Medicaid officials examined care at the local level, they found deep fragmentation: providers operated in isolation, and public-sector programs functioned as disconnected silos that did not contribute to coherent care for individuals or communities.

Community Care of North Carolina (CCNC) grew to encompass 15 regional networks with about 3,500 primary care physicians and more than 1,200 medical homes serving approximately 1 million Medicaid and CHIP patients. Each network received $3 per member per month from the state, while physicians received $2.50 monthly per patient for medical home services. North Carolina set Medicaid payment rates at 95 percent of Medicare fee-for-service levels, which helped attract primary care physicians. Statewide priorities included asthma, diabetes, congestive heart failure, pharmacy management, dental screening, emergency department utilization, and case management for high-cost patients. Dobson reported that savings from improved care coordination more than offset program operating costs, and the state legislature reinvested a portion of the savings into the system.

Geisinger's ProvenHealth Navigator

Janet Tomcavage, vice president for health services at Geisinger Health Plan, described the ProvenHealth Navigator model, an integrated approach to managing complex, chronically ill patients. Geisinger Health System operated across 42 counties in central-northeastern Pennsylvania with 750 physicians, more than 40 community practice sites, three acute care hospitals, and a health plan with 227,000 members. The approach embedded nurse case managers, paid for by the health plan, directly in primary care practices to provide hands-on support for high-risk patients and their families.

Tomcavage noted that when the program began, most primary care sites had no clear picture of their Medicare patient panels — they did not know which patients were assigned to their practice on any given day. Moving health plan data from centralized repositories out to practice sites was a revelation. The goal was for primary care teams to take responsibility for identified patients around the clock, regardless of where those patients happened to be receiving care. The health plan also restructured its payment model, providing upfront payments to primary care providers and practices tied to quality-based incentive programs rather than fee-for-service volume. By 2009, the ProvenHealth Navigator program had expanded to 25 primary care sites with 35,000 Medicare Advantage patients and 15,000 commercial members, and had demonstrated significant reductions in inpatient admissions and readmissions.

APS Healthcare: Targeting High-Cost Medicaid Patients

Stephen E. Saunders, chief medical officer at APS Healthcare, discussed the challenge of managing high-cost Medicaid populations. While children made up the bulk of Medicaid enrollment, aged, blind, and disabled adults accounted for the majority of spending. These adults typically remained in unmanaged fee-for-service Medicaid and had high rates of both chronic disease and serious mental illness.

APS designed programs that engaged providers directly, giving them access to the electronic care records maintained by nurse-health coaches so providers could see medication lists, care plans, and information about other prescribers. In Missouri, physicians who reviewed patients' care plans could bill an additional $25 per patient per month, and those meeting defined quality metrics could earn up to $5,000 annually in bonus payments. Saunders reported that the approach had reduced emergency department use and inpatient admissions, saving Missouri an estimated $150 million annually by slowing per-enrollee spending growth.

Sources and Further Reading

AHRQ — Federal health care quality research agency.

Health Affairs — Peer-reviewed health policy research.

Robert Wood Johnson Foundation — Health policy research.

Commonwealth Fund — Research on health care quality.