A program designed to improve care for people with chronic conditions, like high blood pressure and heart disease, is expected to slash costs for patients, employers and Blue Cross and Blue Shield of Louisiana.
But Quality Blue Primary Care may also transform the way doctors statewide care for those patients.
“Blue Cross is such a big payer, we can influence providers in a way that may benefit other payers’ patients,” said Dr. David Carmouche, who helped develop the program as the company’s chief medical officer. He resigned last week to pursue opportunities outside of Blue Cross.
“If providers are willing to change how they practice, expose themselves to measurement, have some of their payments tied to quality … it’s hard to imagine that there won’t be some spillover impact.”
Blue Cross covers 1.6 million people in Louisiana. Nearly 90 percent of doctors are members of Blue Cross networks.
Most doctors tell Blue Cross they treat patients the same way, regardless of the kind of insurance a person has, Carmouche said. So the improvements that benefit Blue Cross members can also help the rest of a doctor’s patients.
In the year since Quality Blue launched, 450 doctors — in general practice, family medicine or internal medicine — have become participants. Those physicians take care of about 140,000 patients. And the numbers are changing constantly.
Quality Blue began as a quality improvement program. It grew out of Blue Cross-funded research Carmouche did before joining the company. Carmouche found that care varied widely, even among physicians in the same clinic, for patients with chronic conditions, such as high blood pressure, diabetes, heart disease and kidney disease.
Blue Cross wanted to make sure that all its doctors followed best practices in taking care of those patients. Among other things, that meant making sure patients made regular visits to their doctors and followed their treatment plans, taking their medications as directed.
Quality Blue assists doctors and patients to make those changes. The program helps identify patients with chronic conditions, coordinate care for those members, shares their claims-based health information with physicians, assigns quality navigators to help physician practices review appointments, pays doctors a small monthly care-management fee, and works with patients so they become more involved in managing their care.
Under Quality Blue, office-visit co-pays are waived for patients with chronic conditions.
It’s too early to determine the program’s return on investment, or ROI, he said. In the first year of the program, costs may rise because patients are seeing their physicians more often. But as time passes, the savings could be considerable by targeting care for chronic conditions.
The average annual cost for a person with chronic kidney disease is $23,500, according to Blue Cross. But if the condition worsens and the person needs dialysis, the cost jumps to $100,000 a year. The average cost when a person with high cholesterol has a heart attack is $21,500 in the first five days. Forty percent of Louisiana adults have high blood pressure. The average cost in the 90 days after a person has a stroke is $15,000.
About 51,000 of the 140,000 members already enrolled in Quality Blue have high blood pressure, heart disease, kidney disease or diabetes, Carmouche said.
“It’s a pretty target-rich environment,” Carmouche said.
Better chronic-disease management also will prevent the complications that result in costly emergency room visits, Carmouche said.
The average cost of an emergency room visit is more than $2,000, according to the National Institutes of Health.
Quality Blue has already generated a 12 percent improvement in diabetes care; 28 percent improvement in high blood pressure care; 32 percent in vascular disease care; and 69 percent in kidney disease care.
Carmouche said Blue Cross has been able to overcome doctors’ initial distrust by showing them they don’t have to make a significant investment in technology or manpower.
Quality Blue makes it easier to manage those patients and rewards doctors for doing a good job.
Carmouche said Blue Cross targeted large customers first.
Those employers liked the idea of reducing costs by improving workers’ health instead of pushing more of the expense onto employees or cutting benefits, Carmouche said. The large groups’ early buy-in helped when Blue Cross’ leadership told smaller self-funded groups that this is how the company is going to do business.
“We just basically said, ‘This is the only way we see changing the chronic disease cost curve,’ ” Carmouche said. ‘So if you want us to be your third-party administrator, then we expect you’ll participate, and if you don’t want to do it, then you can find a different administrator. ‘ And that was huge.”
Dawn Starns, Louisiana director for the National Federation of Independent Business, said anything that can reduce the ever-increasing cost of health care is a great idea.
Nationally, the direct and indirect costs of heart disease and diabetes alone amount to more than $535 billion a year, according to the American Medical Association. The AMA has targeted these diseases in a nationwide effort to improve treatment and prevention, and to lower health care spending.
Humana, also a major health insurer in the state, also offers a number of services to help patients with chronic conditions and those at risk for developing them. Those services include “Personal Nurse,” where an individual nurse works with members to educate them and help them better self-manage their diseases and health coaching and chronic condition management, said Dr. Laura Trunk, market medical officer and vice president, commercial division.
All those programs are backed by analytics, so a diabetic patient may get an e-alert reminding him to get a blood test, for example.
Humana knows that the programs reduce costs, and member satisfaction rates are high, but the specific savings vary, Trunk said. Some of the savings are inferred: Gaps in care are filled, so a diabetic patient gets her eyes examined, a cardiac patient has his cholesterol monitored.
Dr. Mark Friedberg, a senior natural scientist with Rand Corp., said although these sorts of programs have become more common, their results have been hit and miss.
Some of the efforts work well. In its first year, one large Medicare demonstration project showed cost savings in a couple of regions, Friedberg said. However, Rand found that a project in Pennsylvania didn’t achieve any cost savings during its first three years.
There is no single blueprint for these sorts of projects, Friedberg said. But the federal Centers for Medicare and Medicaid Services and a number of other payers are moving in this direction.
“It doesn’t look like people are going to be turning around and headed back anytime soon,” Friedberg said.
“I think we’re probably going to see a lot more of this in the near future. And then hopefully, in the next couple of years, we’ll have a much better sense, based on a larger body of evidence, of what specific program features produce the best results.”
Follow Ted Griggs on Twitter, @tedgriggsbr.