ANYONE CAN BE DIAGNOSED WITH A CHRONIC ILLNESS – a disease that will never go away and may only get worse with time if it is not properly managed.
Just ask 7-year-old Kelley who was diagnosed with asthma several years ago during a trip to the White House to meet President Bush, or Willie Mae Y, a baking enthusiast who was diagnosed with diabetes two years ago at age 62 (names have been changed due to federal medical privacy laws).
For many people, getting diagnosed with a chronic illness is difficult news to swallow. Many chronic illnesses aren’t life-threatening, but they are life-changing, and if the actual diagnosis itself isn’t bad enough, the orders on how to prevent the illness from getting worse can be downright depressing.
Quit smoking. Give up alcohol. Stop eating sweets and treats. Exercise. Diet. Keep the house cleaner. Don’t create stress. Some of those adjustments are challenging for people to endure, especially on their own. Many people need help – whether its more information, or tips and tricks or reminders or just simple encouragement. Evelyn, Kelley’s mother, needed help when Kelley was first diagnosed with asthma. Luckily, she found it – or rather, it found her.
Evelyn was contacted by a nurse from a company called Matria Healthcare, which offered disease management services paid for by her health insurance provider. The nurse was able to give her clear advice on ways to manage her daughter’s condition – wash bed linens every two weeks, buy new pillows every two months, freeze toys in plastic bags overnight to kill dust mites, vacuum, use no-dye laundry detergent and keep an air filtering system in her daughter’s bedroom.
Kelley’s asthma attacks soon came to a halt. “I learned a lot of things I would never have known on my own,” Evelyn said in a testimonial taken last year for the company. “Kelley Marie is the only one out of all the other asthmatic children [in her school] who has not had to use her inhaler this year, and I like to think it’s partly because of all these things I do to keep her environment clean.” Willie Mae had also needed help managing her illness and accepting the lifestyle changes that came with it. And help found her, too. A nurse at Matria contacted Willie Mae and talked to her about everything from what foods to bake with, how to reduce her stress levels to keep her blood glucose levels low and the importance of scheduling regular appointments with her doctor. “I’ve never been one to go to the doctor,” she said in a testimonial. “Usually, I have to be really sick before I go to a doctor. This program has helped me realize the importance of keeping up with my cholesterol and other things to do with diabetes because if I don’t, I could get kidney disease or have problems with my eyes or feet.” Soon, some members of TAC’s Health and Employee Benefits Pool will begin receiving the same information and benefits as Kelley and Willie Mae, thanks to a contract signed between the health care provider CorSolutions, a subsidiary of Matria, and the recentlyformed Public Employee Benefits Alliance, which allows TAC pool members to consolidate their bargaining power with other Texas local government pools and other independent cities and counties. The new benefits will include a new 24/7 nurse hotline, available to all members, and an expansion of the pool’s disease management efforts to include coronary heart disease and cancer, as well as improvements to the already existing programs for diabetes, asthma and congestive heart failure. The hotline, which members can access by calling 866-676-0740, will be active Oct. 1. It is free for HEBP members to use.
Though the concept of disease management has been around for decades, David Santeusanio, a health management/health promotion and wellness industry consultant for the last 25 years who helped the PEBA pool with its disease management RFP, said such programs have only become popular in the last five years or so, as health costs have risen to new heights. Employers, he said, have realized that paying more for managing diseases helps prevent money from being spent treating the effects of those diseases, should they get out of hand.
They’ve also realized that such programs contribute greatly to their employee’s quality of living, productivity at work and overall health and happiness, he said. Bill Norwood, manager of TAC’s HEBP pool, said one reason TAC was so interested in adding more disease management benefits and the nurse hotline benefits is because the association wants to make it easier for members to take care of their health and make the best health care decisions possible.
“Anybody who has an accident or an illness develop can call this nurse hotline and it will help them go through the decision-making tree,” Norwood said, adding that the hotline will allow members to make better decisions regarding their health and could save people from taking unnecessary trips to the hospital or emergency room. “This can improve the lives of the people using the service,” he said. “Who wants to go to the hospital if they don’t have to?” The fact that TAC could do that while saving money at the same time made the program an even more desirable investment, he added.
The return-on-investment to an employer that focuses on managing diseases can range from saving $2-10 for every $1 spent, but because disease management is a long-term effort, the savings accrued through the program may not be seen until several years have passed.
The cost savings are so great because several chronic illnesses, such as diabetes and heart disease, have severe side effects if they are poorly managed. Diabetics, for instance, can experience damage to the nerves, heart and kidneys, as well as blindness. Some diabetics experience sciatica, a condition where the leg becomes weak, numb or begins to tingle and can cause loss of leg movement and sensation. Diabetes can also lead to strokes and other problems.
Each of those problems not only result in additional complications for the diabetic employee, they also result in much greater and unnecessary financial costs to both the employee and employer, and a loss of productivity. That’s true for any complication stemming from any chronic illness.
Most of those complications are avoidable if the illness is managed properly.
“Asthma is not necessarily going to go away, but with asthma, if its managed well and people are taking their medications and they know how to prevent an incident from getting out of hand, then they don’t have to be rushed the hospital, they don’t have to go to the E.R.,” Santeusanio said.
The most important aspect of managing chronic illnesses, including heart disease and cancer, is knowing as much as possible about the illness. Often, patients just don’t have access to the amount of information and motivation needed to know how to take care of themselves. Having a disease management program where patients can access all the information they need 24 hours a day is extremely helpful.
Santeusanio said the most important quality a good disease management company can have is the ability to educate and address lifestyle issues. “They need to communicate and contact people on a regular basis, be available for them, answer questions,” he said. “On the whole, participants in disease management programs are generally very satisfied with the kind of support they are getting and are very grateful the company offers those benefits,” he added. “If you are somebody who has diabetes or heart disease, your life is dictated by what the disease does, and anything to improve the quality of your life is usually appreciated.”
CorSolutions, the vendor that will be providing the disease management and nurse hotline programs starting in October, is wellknown in the industry for its best practices regarding education, communication and recruitment of employees who would benefit from their programs.
Dennis Richling, the company’s vice president and medical director, said the most important part of the CorSolutions philosophy is that the people in their programs be treated as a whole, and not just as their disease, and to help everyone with a chronic illness, not just those who are faring poorly.
“We identify people with chronic conditions, and what we will find is about 10 to 15 percent of the people will have the most cost. About 5 percent of the people are really not managing their chronic conditions very well at all. Another 10 to 20 percent are maybe doing alright in general, but have some difficulties from time to time. And the rest are managing their conditions well,” he said. “The challenge is, with that group, even though they may be managing it correctly today, that will probably change, just because things happen in life. We get older, and that has an impact on the progression of your disease. You may move from a state where you are managing it well to a stage where you are not.”
In order to help patients during every stage of their chronic illness, the company uses a primary nurse model in which each patient gets their own nurse, who sticks with them for the long haul. Sticking with the same nurse helps clients develop a level of trust that wouldn’t be possible otherwise.
Norwood said the primary nurse and whole person model were the qualities that attracted TAC and PEBA to CorSolutions versus the other vendors competing for the contract, as was its reputation as having nurses who get to know their patients personally.
“It’d be nice to have a nurse in the family watching over you,” he said, adding that that’s what CorSolutions strives to do through its phone calls, reminders and correspondence with patients. “If someone is unable to stay compliant with their treatment program, the CorSolutions nurses are going to find out, why not, what are the barriers, and how can they be removed,” added TAC’s HEBP Operations Manager Jennifer Hall. “You can really impact the disease with this program.”
Hall stressed that the CorSolutions programs are meant to work in conjunction with regular doctor's visits, not as a replacement to having a doctor's advice.
“A doctor may advise a diabetic patient to cut out sweets and simple carbohydrates,” she said. “The disease management nurse would go a step further to advise the individual on living within the doctor's guidelines - what foods to look for in the store, how to read nutrition labels, how certain foods will affect your blood sugar.” Maureen Walsh, who was a critical care nurse for 25 years before becoming a disease management nurse at CorSolutions in 1996, said one of the best parts of her job now is the follow-up opportunities she now has with her patients.
“What I did before was very intensive, but it was also very physical. It was very quick interactions with patients, there was no real before or after follow-up. We did what we had to do in emergency situations,” she said. “What I do now, though, is, I see the whole picture. I see patients, and I talk to them many times before they have a major event and then talk to them after and help them sort out some of the confusing things.
“It can be very rewarding, when you see people finally understand how to help themselves,” she said, adding that she views her role as a safety net. “We are there to catch them and direct them and really help cushion a lot of the changes that they have to go through. It’s pretty intense for some people, especially when they have multiple diseases to have to sort through. It really is very rewarding to help them.”
While some of her patients are self-referred, others are recruited into the disease management program through the claims process. Walsh said getting everyone on board a program is challenging at times, and the most difficult part of her job is making contact with prospective clients. To do that, she makes phone calls and sends packets and letters through the mail.
“Some of them are very resistant, some of them are very reluctant,” she said. “Some people are very open to getting any kind of support or help, and other people think they are doing very well on their own, but they may have other issues to deal with. “A lot of people are resistant to anything new, some people just don’t want to change. But we do tell them, when you are ready, when you feel like you have a question, you do always have someone available to answer that question.”
Sticking with the same patient means that nurses will already have a certain amount of medical history and personal knowledge each time they speak with a client, which is important because it helps the nurses understand what problems a person may be having when it comes to managing their disease.
It is that continuity of care and primary nurse model that has brought Walsh most of her success stories. Many of them are long stories.
One woman, a 43-year-old single mother diagnosed with diabetes, degenerative bone disease and heart disease, started off the disease management program upset at the world, particularly her life, Walsh said. Her biggest complaint was that she couldn’t afford to manage her diseases, but her biggest problem in reality wasn’t her health, it was her outlook.
“It was, ‘I can’t afford this, I can’t afford that,’” Walsh said, adding that insurance can be confusing and frustrating for some people.
“There was this bag of information that was available to her, but she just couldn’t figure it out. … Sometimes, it just helps to have someone say, ‘Well, did you know you have this benefit?’ She just didn’t know she had all these benefits, and she was struggling.”
Walsh was able to convince the woman to participate in a depression program provided by her insurance carrier. The woman hadn’t realized such a program existed. After that, everything else followed. The woman began asking questions about her diet and what programs and benefits her health insurance could provide her. She began checking her blood sugar levels.
“Through some very emotional conversations with her, she really started to see how she could help herself,” Walsh said. “She is now very positive about her health and feels like she is going to make it through.”
Walsh has also helped people with chronic illnesses quit drinking and smoking. She helps her patients prepare for doctor’s visits, reminding them about what questions they’d like to ask and the significance of a specific visit. But the most important aspect of her job is providing patients with reliable information based on their specific condition and health.
“We actually teach, we actually support, and we actually try to empower the patients to understand their health,” she said. “We use all the resources that are out there.”
That’s true also of the nurses who answer the phones at the 24- hour health hotline, said Sally McCarthy, who has worked as a health information specialist with CorSolutions for the past eight years. Her job is to help answer whatever questions come through the hotline and to provide callers with the best advice and information possible.
“The goal is, first, to identify who the person is, and then to identify what their needs are, if they have a symptom or if they have a question. If they have a symptom, the goal is to get them to the best care, whether it be to an emergency room or just self care,” she said. “If they have a question, we give them written materials, or direct them to online resources and other organizations.”
Many of the people she talks to are parents who need reassurance when their children get sick, or people who are experiencing pain and want to know if it’s nothing or if it’s life-threatening. Sometimes, it is.
“People have numbness and they think maybe it’s a pulled muscle, when, really, it’s a stroke,” McCarthy said. “That initial time is very important, that they get the medication they need that prevents a stroke from becoming a permanent disability.”
The same happens with clients who call about experiencing sudden indigestion or who develop rashes. McCarthy is able to ask questions that can help determine if it’s just indigestion or a rash, or something more troubling, like a heart attack or shingles.
“Most of the questions I ask are questions that are pretty direct. Where is the pain? What side of your body? How long have you had it? … Are they having any other symptoms, like sweating or nausea? Is the pain radiating anywhere else in their body?” McCarthy said. “If they have difficulties answering the questions, our job is to probe a little more.”
TAC and PEBA’s choice to buy into CorSolutions’ disease management programs was a calculated decision based on the membership of the participating pools and claims information. The effort focuses on cancer, coronary heart disease, diabetes, asthma and congestive heart failure.
Tumors, for instance, account for 25 percent of the pool’s high cost claims. For the 12-month period that ended April 30, there were 127 high cost claimants – members whose total claims exceed $50,000 – with total payments of $14 million ($3 million spent on cancer claims alone). The other 16,866 pool members who filed claims during that period cost just $35.4 million.
“County employees tend to be older than the average private sector employees. Consequently, expenses for these conditions are way higher than for the average employer,” Hall said. “Heart disease and cancer are the top two conditions for our pool and they take the most money to treat.”
CorSolutions also offers disease management programs for depression, chronic obstructive pulmonary disease and pain, but Hall said those illnesses were not large problems for TAC and PEBA pool members, though the pools may choose to invest in some of those programs in the future.
TAC’s pool membership is 65 percent male and has an average age of 47 years old, meaning that the majority of county employees covered by TAC insurance may be facing chronic health problems sometime soon.
“It’s usually in the late 40s and into the 50s when people start having the health problems that need to be managed,” said Hall. Of course, to really save both employees and employers money and suffering, companies and their workers have to accept disease management for what it is: just one portion of an overall health and wellness plan. Counties and their staff should be taking action before a person’s health gets to the point where chronic disease management is necessary.
“If you just focus on the disease management component of health care, it’s kind of like, you’re a day late and a dollar short. These people are already there,” Santeusanio said. “But you’ve got these other people standing right at the doorstep, ready to be tomorrow’s people with a chronic illness.”
Hall said the HEBP board is working to achieve the goal of reaching those standing on the doorstep – as well as those members who already lead healthy lifestyles.
“This disease management program is really just one component of what we need to build, which is a comprehensive program that supports wellness among our population,” she said. “But to really get to long-term savings, we need to find those people who are healthy today and make sure we have resources in place to keep them healthy, going into the future. That’s what our long-term goal is.