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Insurers tackle managing diseases while maintaining privacy
(St. Louis Post-Dispatch (KRT) Via Acquire Media NewsEdge) Jul. 27--The relationship often begins with a telephone call. Like a telemarketer for health, a nurse calls a patient to inquire about a recent medical visit, diagnosis or questionnaire.
As employers look to lower long-term health care costs, most are turning to disease-management and wellness programs for help. However, some critics worry the programs could infringe on workers' privacy.
Two-thirds of employers are using wellness plans, and more than 40 percent of those using the plans saw them as at least "somewhat effective" in reducing costs, according to a PricewaterhouseCoopers study released last month.
These programs once were the purview of small, specialized vendors. Now, increased demand has moved many of them under the umbrella of the in-surers' medi-cal benefit. The change can provide employers with one-stop insurance shopping, patients with better-coordinated care and case managers with more access to claims data and medical histories.
However, critics question whether administering these programs under the workers' medical benefit has the potential to give employers too much information. The fear is that the information in the programs could cause them to discriminate against workers with certain health issues.
"If (you're) in one of these
programs, the detailed information that's collected, any additional health information is going to work against you in the future," said Dr. Deborah Peel, founder of Patient Privacy Rights, a nonprofit advocacy group based in Austin, Texas. "You might not get coverage again in the future. You might have to pay higher premiums."
However, insurers and other supporters of these health programs say they understand the concerns, but believe adequate barriers exist to prevent inappropriate exchanges of information. And, they say, the most potentially damaging information already sits in insurers' hands through claims data.
With claims data and health information, "there's a firewall that protects" employees, said Carol Antell, a registered nurse and wellness-care manager for Aetna's north-central region.
Anthem Blue Cross Blue Shield of Missouri has moved all of its disease-management and wellness programs in-house. The advantages are a broader program with easier access to patients' claims information.
ANTHEM'S HEALTH 360
Anthem is in the process of launching Health 360, one of the most comprehensive health-management and wellness systems in the industry.
Among its tools are weight, cholesterol and blood-pressure management plans and programs for pregnant women. Other benefits include information on illnesses, local hospital quality and wellness.
Anthem's sickest members have access to a personal health coach, but that's not 360's focus.
"You really want to try to offer a program that doesn't just help the sickest of the sick, but has something for everyone," said Dennis Matheis, chief executive of Anthem. "This is really about quality of life for our members."
Anthem began providing Health 360's full suite of services to all of its fully insured customers in June and says it didn't raise rates to do it. Anthem offers self-insured customers the full package or smaller bundles of services.
"We think it's the right thing to do for our members and the right thing to do from a purely financial perspective," Matheis said.
EASE OF ACCESS
In many cases, incorporating these programs into a standard medical benefit makes them easier for smaller and midsize employers to access.
With boutique vendors, these employers might be contracting with several different companies, each caring for only a handful of workers. The web of agreements often was cumbersome and expensive.
Aetna's programs began in-house, then were outsourced. Four years ago, the company brought the programs back in and added management of 34 dis-eases. At United Healthcare, disease management and wellness programs exist under a separate division within the company. To the public, it's all one organization.
"We really want to make our user experience as easy and streamlined as possible," said Lisa Edenbaum, national director of wellness program development and marketing for United Healthcare.
VENDORS REPLACED
Tammy Collin, a principal with consulting firm Mercer, said she is seeing more insurers replace vendor contracts with staff or purchase a vendor to run programs from the inside.
But she has yet to see any company excel at every component, including case management, disease management and wellness. Documenting interactions, behavior changes and cost reductions also needs improvement, she said.
"There's a lot to be said about identifying people right and getting them to the right place," Collin said. "Can you tell me, the employer, how many people you are doing programs with and what you are doing with them?"
Despite the industry shift, Collin said some standalone vendors such as Healthways still provide clients solid service.
Those programs also face less push back from employees. Easy access to a wealth of claims data is a top reason for incorporating wellness and disease management into the medical benefit.
If a worker is diagnosed with diabetes, there is a claim alerting counselors to make contact. Even the lack of a claim, such as a unfilled prescription, can help a case manager trying to track whether a patient is following doctor's orders.
"To just pay the claims and not use that information to look for commissions or omissions of care, is not in the best interest of the patient," Antell said. "This way you can just zoom right in and approach the gaps."
PRIVACY CONCERNS
But this freer access to information also leads to privacy concerns. Are employers -- specifically those who self-insure and legally are allowed to review claims data -- seeing more-detailed health information? Are those glimpses influencing hiring, firing or promotion decisions?
Edenbaum considers these questions among her programs' "biggest hurdles."
"There is that scratch of the head going, 'Are they talking to each other? Are they sharing personal health information?'" Edenbaum said. "It is certainly a barrier for us that we work diligently to overcome."
Like most major insurers, Edenbaum said information gained by UHC's disease management team stays within the team or is shared with the patient. Employers receive information only in the aggregate. UHC's policies are posted online and passed out to employees.
Julie Eckstein, director of the Center For Health Transformation's Missouri Project, said participating in the programs could make patients more attractive to employers and insurers, if it made them healthier.
The center is a nonprofit established by Newt Gringrich and aimed at making health care more efficient. It sees personal health records, disease management and increased wellness as critical to establishing an affordable health care system.
Peel has a different view. She sees "skyrocketing" medical costs as the top reason employers might peek at private information and shed costly or potentially costly workers.
"If you, as a business, could drop the cost of your premium," Peel said, "it could be a serious temptation."
mjfeldstein@post-dispatch.com -- 314-340-8209
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Copyright (c) 2008, St. Louis Post-Dispatch
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