Intensive care management programs — some of them involving “embedded” case managers in primary care practices — have worked to both improve outcomes and lower medical costs in three major Medicare Advantage plan sponsors, according to presentations at a conference last month. Medical directors of the three plans (Aetna Inc., The Regence Group and Geisinger Health Plan) outlined the programs and results at America’s Health Insurance Plans’ annual Medicare conference in Washington, D.C.

All new MA members of Aetna receive a health risk assessment — which 80% of them complete — plus monthly predictive modeling, said, for instance, Joseph Agostini, M.D., senior medical director. As a result of those processes and of comprehensive screening for members identified through them, Aetna enrolls 18% of the Medicare members in care management, mostly via telephone, he said at a conference session titled “Leading the Way Forward.” And those programs, he added, have led to year-over-year declines in readmission rates in Aetna’s Medicare population.

He highlighted several aspects of the insurer’s Collaborative Care Management Model, including having “dedicated or embedded” case managers available for medical groups serving 1,500 or more Aetna Medicare members. The objective, explained Agostini, is to “close gaps in care” that Aetna finds with the aid of its CareEngine IT system.

One program that has had particularly strong results, according to Agostini, is Compassionate Care. It identifies beneficiaries who are in early stages of “needing advanced care planning” and uses specially trained nurse case managers to help handle their needs. As a result of this program, only about 18% of participating Aetna Medicare members who die do so in acute or subacute facilities, while 81% of them elect hospice care, Agostini said. He adds that this has translated into an 82% reduction in acute care days, an 88% drop in intensive care days and high levels of member and family satisfaction.

Aetna Cites Big Cost Cut Versus FFS

Overall, he said, Aetna’s care management program has reduced costs by more than $120 per member per month versus fee-for-service Medicare and has resulted in 24% fewer emergency room visits, 31% fewer hospital acute care days and 39% fewer stays of more than 15 days.

For Regence’s approximately 90,000 MA members, case management in an “intensive outpatient care program” is more cost-effective than is the “medical home” model, said Chief Medical Officer Herbert Herr, M.D. The one-to-one “interactions” with patients, he asserted, avoid ER visits and hospital admissions.

A big percentage of ill MA members are depressed, he continued, and need interactions with providers. He explained that Regence seeks to foster such interactions by working with provider practices on access, especially in evenings and weekends. This has been more feasible, he acknowledged, in the company’s Washington state and Oregon service areas than in its Idaho and Utah areas.

Geisinger Health Plan (GHP), which has about 50,000 MA members, is in somewhat of a different situation since it is part of a large rural health system in Pennsylvania. The plan has used Geisinger’s ProvenHealth Navigator (PHN) model to improve results in the MA population through such means as employed in-office case managers in its primary care practices, said Q. Thomas Novinger, M.D., medical director, informatics at GHP.

This kind of “bundled care,” he said, has reduced MA member risk substantially in such areas as diabetes and cardiac care. “Embedding the case manager was critical to this,” he contended. GHP, according to Novinger, has found that 15% to 20% of Medicare members need at least some case management, and the plan has a ratio of one case manager per about 800 Medicare lives, compared with one per about 5,000 lives in its commercial arena.

He added that Geisinger makes sure patients are contacted by telephone within 24-to-28 hours after their discharge from acute care.

The results of its PHN program, which now is available at 37 Geisinger sites, have included risk-adjusted acute admissions per 1,000 Medicare beneficiaries of 241 in 2010, compared with 286 in non-PHN sites, Novinger said. Moreover, he said, 2010 readmissions per 1,000 at the PHN sites were 34, compared with 43 at non-PHN locations, and ER visits were 261 per 1,000 versus 296.

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