American College of Physicians: Internal Medicine — Doctors for Adults ®


In N.M., one plan struggles to sell the 'hoopla' of disease management

From the March 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Deborah Gesensway

At Lovelace Health Systems in Albuquerque, N.M., today's economics are intruding on tomorrow's quality improvement plans.

Lovelace is commonly mentioned as one of the most innovative health plans in the nation, in large part because of its disease management programs to improve the care of people with chronic conditions. Now, however, Lovelace is finding it must put some of its quality improvement plans on hold because many employers don't want to pay for them.

"[Quality improvement] really is a long-term strategy," explained Martin E. Hickey, FACP, president and CEO of Lovelace Health Systems. "It's tough getting [employers] to pay for it up front."

Dr. Hickey came to Lovelace nearly four years ago from the University of New Mexico because he wanted to do more than merely talk about population health—he wanted to actually do it.

Lovelace Health Systems was founded as a group practice in 1923 and bought by Cigna HealthCare in the 1990s. It is now a fully integrated health insurance and health care system that includes an HMO, a multispecialty group practice with more than 300 doctors, a contracted physician network, a hospital and several primary care satellite offices around the state. It was the first integrated health system in the nation to receive three-year accreditation from the Joint Commission for Accreditation of Healthcare Organizations and also has full three-year accreditation from the National Committee for Quality Assurance.

Lovelace's disease management program, called "Episodes of Care," began in 1993. As part of the program, providers track all patients with about 15 different diagnoses ranging from asthma and diabetes to breast cancer and depression.

The plan focuses on identifying patients early in the course of their disease. These patients are then put on up-to-date therapeutic regimens, as determined by teams consisting of doctors and other health care providers who develop protocols after studying best practices nationwide. At the same time, the patients are educated about their conditions and taught how to follow the regimens. A case manager then follows up regularly to reinforce the new behaviors. The goal is to reduce the need for expensive, acute care that can develop otherwise—such as ER visits for an asthmatic. There is already some evidence that this system works.

In Albuquerque, however, where premiums for employers have dropped up to 15% despite rising costs for health plans, it's very difficult to expand—and sometimes even sell—the program.

According to Dr. Hickey, the sticking point is whether employers find the additional costs worth it. One health plan says "we'll provide all the basics—delivering acute care when you need it, having care available and letting patients have a choice—for $95," he said, "and Lovelace is going to charge $100 and give you all this hoopla. The employers naturally ask, 'Do we really want the hoopla? Will this hoopla pay off?' ... In the long run it does, but selling it is a different story."

As a result, Dr. Hickey said, Lovelace has found it has had to go slower than planned in instituting important parts of its disease management programs—particularly case management—to reinforce protocols and patient education. "We're certainly maintaining the gains we've made," he said. "We just won't be able to expand the program in our ideal format that we had laid out a few years ago."

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