Health Dialog implements what it learned from MHS
As one of the leaders in disease management (DM), Boston-based Health Dialog knows how to reach and engage patient populations in the commercial setting.
In signing up for the Medicare Health Support (MHS) project, the DM company—which had extensive experience serving senior and Medicare lives—hoped to learn more about working in the specific Medicare fee-for-service (FFS) setting and implement that knowledge into its wider book of business.
The MHS project allowed Health Dialog to “dive deeper” into the senior population, where it learned about the importance of targeting the right people, supporting them appropriately, getting timely information, and the critical role that providers play in healthcare, says Molly Doyle, vice president of government programs at Health Dialog.
Health Dialog quickly found many unexpected beneficiaries involved in the project. There were seniors who were near death and institutionalized who DM could not help and also those who experienced a chronic condition at one time but were in fine health at the start of the MHS project, both of whom were less likely to benefit from a DM program. These groups needed program refinements, and Health Dialog and others enhanced programs throughout the course of the pilot to better serve their population.
The 10% most costly beneficiaries in Health Dialog’s project were seven times more costly than the average cost of a Medicare beneficiary, Doyle says. Many of them were cognitively impaired and/or institutionalized, so the organization was only able to engage them through health partners (i.e., family and friends) when they could be identified. Meanwhile, more than half of beneficiaries cost about one-third of an average Medicare beneficiary, meaning DM could not save much money by avoiding hospitalizations and other medical care.
Having patients at either extreme reconfirmed the importance of choosing the right people for DM. “Targeting the right population is essential, and having the data to target people when they need support is critical,” Doyle says.
When signing up for the project, Christopher Coloian, senior vice president of health services at Boston-based Health Dialog, says the company expected that heart failure patients would have at least two medical claims for heart failure, which are the kind of people DM programs would usually target. But CMS added beneficiaries who didn’t fit that criteria and were, in fact, healthier.
One of the problems was that CMS chose beneficiaries approximately 18 months before the MHS project began, which meant those patients could have experienced wide varieties of health improvements or setbacks, Coloian says. In the commercial setting, Health Dialog receives hospital admission information daily and full claims data within 30 days after an episode, as compared to 60–90 days in the MHS project. The time lag in the MHS project meant that Health Dialog could not connect with at-risk beneficiaries during the critical window right after diagnosis or hospitalization.
In commercial-setting hospital admissions, data are received daily, whereas CMS was not able to provide this information at all. Health Dialog developed a work-around to receive notification of hospitalization through the fiscal intermediary for its region, but still resulted in a 10–14 day delay in notification from the date of admission.
However, the work-around wasn’t in place until six months into the three-year project, which means the second interim report may not have been affected by the data exchange improvement. In addition, medication claims data were not available from CMS until after the 18-month evaluation, according to Health Dialog.
“In the first 18 months, you’re looking through a window where some of the MHS pilot infrastructure and design issues were having to be mitigated by innovation and learning,” Coloian says.
Having more up-to-date information allows the DM company to reach out to the person when he or she could most be open to change behavior, such as at the time of hospitalization or a new diagnosis, Doyle says. “If you find out about someone going to the hospital five or six months later, the window is closed,” she says.
Health Dialog actively engaged physicians in the MHS program through outreach and sharing clinical data, and physicians were receptive to this outreach. However, this population would typically require much more intensive physician engagement.
CMS randomized the beneficiaries rather than the providers, which meant that Health Dialog couldn’t communicate with the physicians without contaminating the control and intervention group separation, Doyle says.
If the randomization scheme was different, Health Dialog would have had more extensive integration with providers. Because the population was randomized at the individual rather than provider level, members of the control and intervention group would be affected by the physician activities, Coloian says.
“[Randomizing beneficiaries rather than physicians] also diminished the number of lives that were within any individual practice, so there was very little concentration of intervention group members within a practice.
MHS was an opportunity for the industry to learn more about caring for Medicare beneficiaries in the FFS program, Doyle says. Determining how best to work with patients from different patient populations takes time, and the MHS interim results show that learning process.
“This was the first large-scale effort to implement care management/disease management in the fee-for-service setting,” Doyle says. “It took the managed care industry many, many years to develop the infrastructure to support care management. We understand that it will take time to do the same in the fee-for-service environment and know there would be challenges along the way.”