Managed Care and Voluntary Health Organizations

Managed care organizations and voluntary health agencies unite to improve care

By Ian R. Lazarus, FACHE

One of the great ironies of healthcare delivery stares us plainly in the face and yet rarely do we recognize it. Like two performers playing to a crowded audience, yet blindly unaware of each other's presence, managed care organizations and voluntary health agencies go about their business providing care and support to millions of Americans. Their constituencies and messages overlap, but there is no formal mechanism in place to provide for a productive exchange of knowledge, ideas and inspiration. Meanwhile, voluntary health agencies have become mature, sophisticated enterprises with carefully formulated strategies for reaching their goals. And so this message goes out to the leadership of managed care organizations everywhere: "best practices" in disease management may indeed be available....and it may even be free for the asking.

The lack of coordination between managed care and voluntary health agencies, or "VHA's," is not so surprising when one considers the significant differences in how they measure success. Indeed, while most managed care organizations focus on providing the right care and appropriate resources when needed, VHAs focus on providing as much information as often as possible. VHAs typically represent the voice of a challenged constituency, and they want as much visibility as possible for their cause. Managed care organizations, on the other hand, would prefer to go quietly about the business of providing healthcare services at a reasonable profit. These days, it seems that to seek too much exposure for this business model can be dangerous, particularly if the profits ever come at the expense of quality care and customer satisfaction.

Still, some MCOs have determined that it is good business to support VHAs, and to cultivate goodwill through grants and funding for special projects. But such arrangements are necessarily one-way transfers, generally restricted to contributions of capital, and not involving any transfer of knowledge from the VHA to the MCO. Why don't these relationships go any farther in reaching the tremendous potential they can offer?

The why of working together

Although collaborating with voluntary health agencies can make good business sense under nearly any circumstances, a compelling reason in itself may draw from consumer perceptions toward plans that go it alone. Kaiser Family Foundation finds 36% of 2500 people give health plans a "C," "D" or "F" on a health plan "report card." Consumers believe only tobacco and oil companies do a worse job than health plans at serving customers (according to a Harris Poll), with satisfaction levels dropping dramatically from 51% to 29% since measurement began in 1997. Harris' Chairman suggests further that the factors causing negative perceptions toward managed care are still in place, and will likely continue to have a negative impact for years.

Meanwhile, voluntary health agencies enjoy an enduring "halo effect" from the nature of their work and mission. Donations to health charities reached $18.8 billion in 2000, a 4.9% increase according to AAFRC Trust for Philanthropy, and nearly 10% of all charitable giving. Pharmaceutical companies recognized long ago the benefits of affiliating with a source deemed more trustworthy than themselves by the general consumer population. Managed care organizations would do well to affiliate with organizations operating in the same industry, with similar goals, but dramatically higher levels of confidence.

"Managed care organizations need to be more aware of just how sophisticated these voluntary health agencies have become," suggests Myrl Weinberg, President of the National Health Council. The National Health Council represents over 100 national health related organizations, including the 50 key patient-based health associations, such as American Heart Association and American Cancer Society. "At the same time," she adds, "voluntary health agencies need to focus on what managed care organizations need: resources that support their objective to provide quality healthcare at a reasonable cost." Weinberg goes on to suggest that collaboration around the development of evidence-based practice guidelines may be an ideal starting point. "Offering support for the 'PR' value alone provides no lasting benefits to either organization," she adds.

A tapestry of collaborations

Its not possible to discuss models for collaboration between MCOs and voluntary health agencies without recognizing the partnership established between AAHP and the American Diabetes Association. In 1998, the Board of AAHP endorsed a strategy to establish partnerships with national organizations to specifically leverage community-level efforts that would collectively bring national change in the approach to delivering chronic care. The partnership with ADA is the first of these initiatives, launched officially in 1999 with the hopes it will ultimately serve as a prototype for other chronic conditions such as asthma and heart disease.

The "Taking on Diabetes" campaign is multi-faceted: collaborations with MCOs, state health departments, peer review organizations and professional medical societies are focused on disseminating information related to the disease and on the development of clinical practice guidelines based on evidence-based medicine. The program has ambitious and aggressive goals:

  • To reduce irreversible vision loss through early detection and intervention
  • To reduce the development of End Stage Renal Disease for members with diabetes
  • To reduce the loss or partial loss of lower extremities from the loss of blood circulation and foot ulcers for persons with diabetes
  • To reduce the risk of cardiovascular disease associated with diabetes

The program has published baselines and targets in connection with each objective, and participating members can access a robust database of best-demonstrated practices in exchange for their "pledge" to support the goals of the program (see www.takingondiabetes.org). Approximately 200 health plans have taken the pledge, effectively providing early detection and intervention coverage for 75 million people, more than 4 million of them with diabetes.

A separate component of the program targets workplace interventions. Working with the Employers' Managed Care Health Association, Taking on Diabetes conducts a needs assessment of employers and also developed a directory of work-site programs. "Taking on Diabetes is a wonderful example of a collaboration that allows the voluntary health agency to bring tangible value to the managed care organization," notes Ms. Weinberg, who served at ADA ten years before joining the National Health Council.

Taking aim at asthma

Asthma is the most common chronic childhood illness, and it is a leading cause of school absenteeism, often leading to workplace absenteeism at the same time. Since 1980, the number of Americans suffering from asthma has jumped 154 percent, to 17.3 million, and the Centers for Disease Control predicts this number may double again in the next 20 years. Of this amount, nearly 5 million are children.

Various theories exist for the rapid rise in the incidence of asthma. A commonly held belief is that the very high standards of sterilization we establish for newborns has caused their immune systems to fall short of environmental pollutants and airborne agents encountered later in life.

The state of Florida has a disproportionate share of asthma sufferers, and in Hillsborough county that rate has risen from 2.7 percent to 7.1 percent in just four years. Nationally, about 4.3 percent of children are considered asthmatic. "People are starting to say this really is an epidemic out of control," notes Patrick Ewing, M.D., a pediatric pulmonologist and asthma specialist at All Children's Hospital in St. Petersburg.

In steps AvMed Health Plan, the state's largest not-for-profit health plan, serving 300,000 members throughout the state of Florida. Although their own asthma disease management program, "EZ Breathin'" had been producing dramatic reductions in hospitalizations, ED visits, and doctor visits related to asthma, they decided to direct new support toward the "Open Airways for Schools" program of the American Lung Association. AvMed formed a partnership with ALA to combat asthma throughout the state. They not only directed new funding to the program, but they cooperated to secure incremental grant funding, and work directly with the ALA in brining training materials and programs to schools throughout the state. Since the partnership to market the program began in 1999, more than 2500 students in 88 schools have participated in programs that help them manage their asthma. Another 1000 students are expected to participate next spring.

  Before E-Z Breathin' After E-Z Breathin'
Hospitalizations 40% 9%
Hospital LOS 9.5 days 4.5 days
Emergency Room Visits 38% 7%
Unscheduled Doctor Visits 51% 7.7%
Source:1997 pilot program of 200 members, AvMed Health Plan

The relationship with the ALA goes beyond simply writing a check. Clinical expertise from the ALA has been used in developing disease management protocols within AvMed. Joint training programs in the schools help AvMed staff to deal with the challenges of serving their own members. And to sustain the high degree of collaboration required for the partnership to work, AvMed representatives serve on the local advisory boards of ALA.

The success of this project demonstrates the potential from a bi-directional exchange of ideas and information. AvMed's leadership recognizes the potential from such collaborations, and company executives are required to submit written goals related to the implementation of similar community projects as part of their performance criteria. "As healthcare enterprises, we still don't know how to compete and collaborate at the same time, but we're learning," notes Bob Hudson, CEO of AvMed. "Collaboration in itself is a full time commitment," he adds.

Creating a new model for caregivers

One of the great challenges of The Alzheimer's Association is to ensure that neither physicians nor family caregivers "give in" to the disease. The healthcare industry has made great strides in the last 20 years with respect to diagnosis and treatment, but even today the transfer of this information seems encumbered by perceptions that there is little that can be done for patients with dementia. Worse than this, there is a discrepancy between what family caregivers expect from physicians and what physicians indicate they have in fact provided during the treatment of patients with Alzheimer's.

The problem in treating Alzheimer's deals as much with social attitudes as with practical problems in diagnosis. Family members have difficulty in recognizing the warning signs of the onset of the disease, and physicians may not provide or document the diagnosis even when it is recognized or suspected. Even when the discussion of a possible diagnosis is in the open, families complain that physicians are unable to provide information that enables them to provide a better quality of life for the patient, and the available social services network does little more to help them deal effectively with the condition.

Recognizing their ability to take existing knowledge and techniques and to facilitate better implementation of care for Alzheimer's patients and families, the Alzheimer's Association joined with the National Chronic Care Consortium to create the Chronic Care Network for Alzheimer's Disease (CCN/AD). The project subsequently selected 7 managed care sites to implement the program, which is composed of four principle phases:

  • Identification of people with possible dementia - a three step process used to identify people who may have AD and who should be targeted for a diagnostic assessment
  • Diagnostic assessment - a comprehensive review of medical history, physical and mental examination, lab tests and imaging to substantiate a diagnosis
  • Care management - Disease management protocols ("blueprints") that identify areas for assessment, goal formation interventions in medical treatment, nutrition and advance directives, and desired outcomes
  • Family caregiver information and support - a conceptual framework that defines the phases of caregiving based on the competency level of the caregiver

Each site represents a partnership between the local Alzheimer's Chapter and the managed care organization. Sites are provided the flexibility to adapt the Care Management protocols and to establish a productive working relationship with the Program. As a result, some sites make joint home visits to Alzheimer's patients, while others e-mail care plans back and forth to reflect progress made by each member of the team providing care. The commitment to this program in one area has come to transcends the leadership of the managed care organization providing the care: after two acquisitions of the plan, the CCN/AD program remains actively in place.

Partnering organizations in Chronic Care Network for Alzheimer's Disease

Denver:
Centura Health, PacifiCare of Colorado

Minneapolis/St. Paul:
Amherst H. Wilder Foundation/HealthEast, Fairview Health Services/Ebenezer Society, UCare Minnesota

Philadelphia:
Philadelphia Geriatric Center, Temple University Health System

Sacramento:
Sutter Health

San Francisco:
Goldman Institute on Aging, Kaiser Permanente (Northern California), Brown & Toland Medical Group

Troy/Albany:
Northeast Health/The Eddy Capital District Physician's Health Plan, State University of New York School of Social Welfare

Upstate New York:
Upstate New York Network of the US Department of Veterans Affairs

Note: Local and Regional Chapters of The Alzheimer's Association are also considered "Partner" Organizations in each CNN/AD Site.

Source: The Alzheimer's Association

The downside of doing nothing

The Alzheimer's Association, like other large voluntary health agencies, is not stopping with the strategic expansion of these pilot programs. In fact, the Association launched a 24-hour advice "hotline" earlier this year with seven demonstration sites and plan to expand nationally over the next few years. Originally designated as a "personalized knowledge service," the program provides direct referral to local Chapters of the Association, and it can also provide general information on Alzheimer's disease through social workers and other trained personnel. "Ultimately, we wish to establish and communicate the norms for how to effectively treat the Alzheimer's patient," notes President Alan Stone. "We prefer to do this in collaboration with the managed care community, but we will pursue this goal in any way we can."

Establishing these medical advice lines represents an effective vehicle through which voluntary agencies can reach out to establish a level of "intimacy" with their key constituents. And "reaching out" may be an understatement: the American Cancer Society call center now manages 1.2 million calls per year. These programs employ the latest in call center technologies and strive for high levels of service. The ACS call center, for example, answered 90% of those 1.2 million calls in 30 seconds or less.

The end of Act 1

The movement of voluntary health agencies into the "CRM" (Customer Relationship Management) arena foreshadows a national development that might catch MCOs by surprise. Healthcare organizations of all varieties are investing in CRM programs to establish intimacy with their clients and prospective customers. And this presents an interesting dilemma for the MCO. What happens, for example, when consumers begin to increasingly rely on the voluntary health agencies for treatment advice? For best practice information? For advice on selecting a managed care plan? Whether by choice or by chance, our two stage performers are about to be turned squarely toward one another, face to face. On to Act 2.

Ian R. Lazarus, FACHE is on the Editorial Advisory Board of MHE. He is also managing partner of Creato (www.creato.com) a consulting firm providing strategic advisory services to healthcare providers and suppliers.

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