HMOs don’t trumpet their excellence at managing chronic conditions–they’re afraid of attracting a disproportionate number of expensive members. And excellence is by no means the norm. Only 16 out of 96 plans in NEWSWEEK’s 1998 HMO ranking won the highest grade for adult disease-management programs. To spot a topnotch program, check to see how well it does in each of these areas:
Screening. Chronic conditions are easier to manage if they’re recognized early. Plans such as Fallon Community Health Plan and Tufts Health Plan for Seniors give new subscribers an independently vetted risk-assessment test. If a plan can’t tell you how many of its members have asthma or diabetes, chances are slim that it has a decent disease-management program.
Monitoring. At Crozer Keystone Health System, in Springfield, Pa., new subscribers with congestive heart failure must sometimes feel they’ve gained a family member. Nurses visit them at home as often as three times a week for the first 12 weeks. And after the visits taper off, members get recorded phone calls, quizzing them about their weight, medication and basic functioning. Those who don’t like talking to machines can punch a button to get a nurse instead.
Teaching. When you have a chronic condition, everything depends on your skill at ministering to yourself. “Patients with congestive heart failure have a tendency to be frequently hospitalized because they don’t take their medication correctly or they don’t realize their condition is worsening,” explains Dr. Ian Jones, chief quality officer at Crozer. A serious program strives to turn members into experts, offering both one-on-one instruction and group classes.
Gauging Success. A program should closely monitor its own success at helping people. The typical yardstick for assessing asthma care is the number of emergency admissions. But the Foundation for Accountability (FACCT), a health-care advocacy group in Portland, Ore., recommends broader and subtler criteria–the number of days asthmatics couldn’t carry out their regular activities, the percentage reporting mild to moderate symptoms, the percentage versed in using inhalers and peak-flow meters, and so on. To find out which assessments you should look for, check the Web sites maintained by FACCT (www.facct.org) and the National Committee for Quality Assurance (www.ncqa.org).
Setting Goals. It’s not enough for a health plan to say it wants to reduce diabetic complications. Besides asking the plan’s administrators how many incidents of blindness, kidney disease, coronary vascular disease, foot problems and amputations its diabetic members suffered last year, ask how many fewer it expects next year. Treatment should follow nationally recognized guidelines, which you can usually obtain through the local chapter of a national voluntary disease organization. Visit the National Health Council (www.healthanswers.com) to find organizations’ Web sites or check out the National Guidelines Clearinghouse at www.guideline.gov.
Making Progress. No program can guarantee good health to everyone, but the best ones can demonstrate improvement over time. Crozer Keystone says that when people with congestive heart failure go through its program, they reduce their chances of hospitalization by 60 percent. Group Health of Puget Sound saw its diabetic members’ glucose levels drop about 5 percent last year, which means fewer complications. But the program’s most striking achievement is just ahead. Because it began routinely testing for kidney damage 18 months ago, Group Health has been able to prescribe a kidney-protecting drug for most of the diabetics who need it. The payoff? “We should see a drop in the number of diabetics with end-stage renal disease in a couple of years,” says Dr. Hugh Straley, the plan’s associate medical director.
If you’ve been smart enough to find good treatment without the help of a disease-management program, you’ll be wise enough to realize that such programs bear investigation. After all, the goal isn’t to let your condition consume all your mental energy–it’s to live as though your ailment didn’t exist.
