Study looks at health care program

In partnership with Blue Shield of California, the Laboratory for International Data Privacy at Carnegie Mellon University has proven that a patient-centered case management program for severely ill patients results in cost reductions of more than $18,000 per patient.

The patient-centered case management program (PCM) is a personalized care management program that assigns nurses to each patient. Through PCM, these nurses help educate the patient on their treatment options, health care services, and pain management options.

By organizing patient care to fit the individual needs of patients, PCM has been proven to help patients avoid unnecessary hospitalization and emergency departrment visits.

For this study, PCM was provided by ParadigmHealth. This study also required that all of the participants be complex care patients, or patients who have a clinically advanced illness and the presence of at least two diseases.

Seventy five percent of the patients in this study were Oncology patients. Andrew Halpert, senior medical director of Blue Shield of California, stated, “The kinds of diseases that PCM deals with cannot be prevented. Most of the patients managed by PCM have already received appropriately aggressive treatments.”

In the study, 756 Blue Shield of California Health Maintenance Organization members were followed for 18 months. About half of these candidates received PCM; the 16-nurse and two-physician team from ParadigmHealth spent an average of 10 hours per patient per month.

All 358 patients in the PCM cohort received an initial phone call and were contacted, on average, 14 times per month. Providers and the health plan (a subscription-based medical care arrangement working with Blue Shield) made an average of 10 calls per month. ParadigmHealth made about 18,240 phone calls to patients, providers, and the health plan.

At the end of 18 months, the patients who received PCM made different treatment choices, such as less radiation and chemotherapy among oncology patients. Given reported death data in the American Journal of Managed Care, the “extra” chemotherapy and radiation experienced by the other half of the cohort did not seem to produce any survival benefit.

PCM patients were also more proactive with their care plans, which resulted in fewer symptoms stemming from impatience, such as nausea and anemia.

This decrease in facility-based treatment found in hospitals and emergency departments and the increased use of outpatient services such as a hospice or home care decreased expenses by 26 percent per patient.

In the American Journal of Managed Care, where this study was first published, the article stated that frequent contact enabled nurses to notice potential lapses in care. The researchers used the example of a brain cancer patient about to run out of his anticonvulsant. The registered nurse was able to organize delivery of medication to this patient, thereby preventing seizure, possible aspiration, an emergency department visit, and hospitalization.

Overall, the study concluded that PCM patients resorted to less costly home care and hospice care instead of costly hospital and emergency room visits.

According to a Carnegie Mellon press release, “Hospital admissions were reduced by 38 percent, hospital days were reduced by 36 percent, emergency room visits were reduced by 30 percent, home care was increased by 22 percent, and hospice use was increased by 62 percent.”

The Carnegie Mellon press release summarized the financial outcome of the program. “The average combined utilization cost of the PCM cohort was $49,742 per patient for the 18-month study duration. Compared with $68,341 in the usual
case management cohort, this amounts to an average savings of about $18,599 per patient.”

With these results, the first of its kind, Blue Shield of California offered PCM to its entire member population.
This more “holistic approach,” as described by Halpert, not only provided more synchronized, cost-effective care than traditional management but also satisfied the patients who received PCM.

Latanya Sweeney, head of the Data Privacy Lab, stated, “This is great news for those who face some of the most expensive complex health care needs.”

As of today, the prevalence of complex care patients is, “one out of 1000 in the commercially insured population and 5- to 10-fold higher in the Medicare population,” according to the American Journal of Managed Care.

In addition, Halpert said he hopes that “other health plans and delivery systems (most notably Medicare) would consider a similar PCM approach.” He said that so far “no other health plans in California have initiated PCM, but that some other plans in other parts of the country have implemented a similar program.”

“No other program has assessed outcomes with a study design as vigorous as Blue Shield of California’s,” Halpert said.