An acquaintance of disease management guru Al Lewis was in a 500,000-member health plan. The acquaintance, who had a history of heart problems, went to the ER for unrelated symptoms. There, it was discovered that his systolic blood pressure was well over 200, and he had severe hypertension. Three months later, he had not been contacted by the health plan about managing his condition. Lewis called the health plan himself and established that contact proactively.

"Without my call, the disease manager said that contact still might have been delayed another month because the claim was filed late and was only then at the back of the queue," says Lewis, MANAGED HEALTHCARE EXECUTIVE editorial advisor and president of the Disease Management Purchasing Consortium International, Wellesley, Mass.

It could be many months between the time when a patient—such as Lewis' acquaintance—is diagnosed with a condition and when the patient actually completes a call with a disease management service.

Abir Sen, chief strategist at RedBrick Health, a health services company in Minneapolis, agrees with Lewis. "A 105-day timeframe is not adequate," Sen says. "We need a business model that is focused on getting the right support to the right person at the right time. The current business models in the industry fail at doing this because they do not have everybody's incentives and capabilities aligned."

Barry Lachman, medical director at Dallas-based regional Parkland Community Health Plan (PCHP), which has 140,000 members—91% of them are younger than age 18—explains what might happen during that 105-day lag.

"The claim takes 15 to 30 days to be submitted," Lachman says. "Then the claim is processed another 15 to 30 days. The data is extracted monthly to identify patients with claims—up to another 30 days. The data is transmitted to the vendor, and the identification process at the DM vendor is done, which takes another couple of days. Finally, efforts are made to contact the member. When you look at DM, the wonder is that it works with these delays in engagement. Just imagine how much more powerful the result becomes if you can reach the member more quickly, especially in Medicaid where the length of enrollment is generally shorter."

INITIAL IDENTIFICATION

OptumHealth Care Solutions, part of UnitedHealth Group, whose services are available to about 58 million consumers, recognized several years ago the need to take an integrated approach to gather input from multiple sources well beyond claims, according to Chief Clinical Officer Harlan Levine, MD. For example, up to 20% of calls received by the nurseline are from recently diagnosed members who have questions about their treatment options. The incoming calls help with real-time identification.

Reaching the member as quickly as possible enables health plans to seize a teachable moment and drive behavior change, according to Lewis.

"Behavior change is most possible at teachable moments, and the most teachable moment is right after someone is diagnosed," he says. "It's unrealistic to think that any behavior change is going to be possible 105 days after the fact. Savings is only possible through behavior change. If it's taking 105 days to contact someone, that casts serious doubt on the plausibility of savings estimates."

Annette Ruby, vice president of health services management, at SummaCare Inc., in Akron, Ohio, agrees that an often-overlooked opportunity for effectively intervening is at the point of diagnosis.

"An opportunity exists for case and disease management programs to stratify their populations and target newly diagnosed patients with interventions to position patients from the start to successfully manage their chronic conditions," Ruby says.