Grassroots programs tackle healthcare problems
A BlueCross BlueShield Association (BCBSA) program is using a bottom-up approach in hopes that a grassroots effort can improve healthcare.
Rising costs, fractures in the healthcare system, quality-of-care weaknesses, disparities in care, and the uninsured are all areas of concern in healthcare, but rather than wait for a nationwide initiative to spark change, BCBSA’s BlueWorks tries to inspire local market innovations that can drive change.
Three examples of BlueWorks programs are BlueCross BlueShield of Texas’ statin therapy enhancements, Highmark Blue Shield’s Caring Program, and BlueCross BlueShield of Louisiana’s Smart Bodies.
BlueCross BlueShield of Texas
BlueCross BlueShield of Texas initiated a pilot program with a large national employer with more than 43,000 insured members to increase patients’ adherence to their statin drug therapy.
For those with high cholesterol, statin drug therapy can help lower the risk of a heart attack or other serious cardiac events, such as myocardial infarction. However, studies show that only half of people who are prescribed the drugs after a heart attack adhere to the prescription regimen one year after the attack.
Physicians are prescribing statins, but they don’t know if their patients are actually refilling prescriptions, says Tom Tran, PharmD, divisional vice president of pharmacy programs at BlueCross Blue Shield of Texas in Richardson.
“They have to take their patients’ word for it because they don’t have a mechanism of knowing whether it was really filled at the pharmacy or not,” says Tran, adding that many patients stop taking their statins because cholesterol doesn’t cause pain, so they think there isn’t an immediate need.
BlueCross BlueShield of Texas’ program sought to increase patient use of statins and reduce physician overutilization of brand-name statins. The difference between brand-name compared to generic statins is more than $100 per month, Tran says.
BlueCross BlueShield of Texas uses pharmacy claims records to find at-risk members who are not adhering to their prescribed statin regimen. The health insurer notifies the patients’ doctors quarterly as to whether the patients are refilling their statin prescriptions. The doctors, in turn, follow up with the patients, according to BlueCross BlueShield of Texas.
Getting physicians onboard was critical to the program’s success, Tran says, adding that patients follow their doctors’ advice more than their health insurers’.
For the other part of the program, the insurer encouraged generic statins through a pharmacy-benefit step therapy plan.
The pilot program showed an increase in statin use among at-risk members: Out of every 17 at-risk members whose healthcare provider received notification of statin therapy, one person increased his or her statin use.
The added cost for increasing statin use was offset by doctors prescribing more generic medication, saving the health insurer $26,000 annually. If those savings were spread across all BlueCross BlueShield of Texas members, the health plan would save more than $2 million in drug costs—and that doesn’t include medical avoidance costs, according to the BlueCross BlueShield of Texas.
The insurer may expand the program next year to other disease states, including diabetes, hypertension, and asthma, Tran says. “I think the main thing is we have to continue to leverage our partnership with our physicians,” he says. “We have to help physicians with the information gap so they can have that conversation (with patients).”
Highmark Blue Shield
The Pittsburgh-based health insurer’s Care Foundation launched the Caring Program in 2004 as a way to empower children with special healthcare needs and their families, as well as help them navigate the healthcare system maze. More than 8,500 children and families in the Children’s Health Insurance Plan through Highmark have received services in the Caring Program, 76% of whom have comorbidities, including asthma, epilepsy, muscular dystrophy, and diabetes.
“I think one of the strengths of our program is we identify what that family’s unmet need is and help them find the resources to meet it,” says Mary Kay Holleran, RN, director of Highmark Blue Shield’s Care Foundation in Pennsylvania.
Highmark employs 10 community-based nurse care coordinators to provide better and more efficient care to children with special healthcare needs which, in turn, reduces financial and emotional stress on the families, according to the insurer.
The keys to the Caring Program are communication, coordination, and collaboration among systems and empowering the children, families, and healthcare providers with information, education, and tools, explains Holleran.
The program offers the following two levels of support, depending on the severity of the child’s diagnosis and other information:
The program creates individualized care plans, educates families about diagnoses and community resources, and helps families prioritize needs and address housing, food, heat, and emotional support issues.
An important part of the program is empowerment, Holleran says. “We’re of the belief we want to teach them to fish rather than feed them the fish,” she says.
The care coordinators work with the individual child’s physicians by sharing the member’s care plans, providing nonmedical referral information, and assisting in coordinating care and communication among multiple facilities.
“The communication is not always that good [between physicians], and the parents are left frustrated by that,” says Holleran, adding that the program has held conference calls with medical teams to get everyone on the same page for the child.
They also help families communicate and educate their children’s schools to ensure a safe, inclusive environment.
Holleran says teachers are often not given the proper tools to help children with special healthcare needs, such as the case of two diabetic boys who were being homeschooled by their mother because the public school did not know how to properly care for them during the school day. A Caring Program nurse care coordinator went to the school and taught staff members about diabetes and how to care for the boys. Because of the program, the boys reenrolled in the public school.
The University of Pittsburgh Graduate School of Public Health and School of Nursing evaluated the Caring Program and found it decreased emergency room visits and inpatient hospitalizations by 50%, increased prescriptions, and improved the quality of life for children and their families.
Students missed fewer school days, experienced fewer problems in school, participated in more extracurricular activities, and families spent less out of pocket and felt a decreased level of anxiety.
Highmark is exploring whether to expand the program to the entire pediatric population, Holleran says. “It moved mountains for a child,” she says.
BlueCross BlueShield of Louisiana
Knowing that overweight children often grow up to become overweight or obese adults, BlueCross BlueShield of Louisiana created a program to encourage elementary school children to adopt healthier behaviors.
“We have a huge problem with childhood obesity,” says Christy Oliver Reeves, executive director of the BlueCross and BlueShield of Louisiana Foundation in Baton Rouge, LA. “As a health company, we know obesity is a problem regardless, and I think 80% of kids who are obese become obese adults. We thought if we can address that then it would impact the state in a beneficial way.”
Smart Bodies was developed as a partnership between BlueCross BlueShield of Louisiana and Louisiana State University (LSU), which teaches children about nutrition and the importance of physical activity.
The program, which has a special emphasis on limited-income youth, sends monthly newsletters, activity books, and curricula to participating schools and parents or guardians.
Smart Bodies includes the following three components:
Smart Bodies met its five-year goals in three years, going to 300 schools in 55 parishes, and touching the lives of 125,000 children. That accomplishment is more impressive because Hurricane Katrina wiped out a whole semester of classes that Smart Bodies needed to reschedule, says Oliver Reeves.
The programs are linked to the Louisiana Department of Education grade-level expectations. Getting LSU involved in the project was critical to its success because the insurer didn’t have the infrastructure or relationship with the public schools that LSU enjoyed, Oliver Reeves says, adding that LSU was an organization that educators respected and trusted.
“We did have some barriers with some schools when we first started in terms of understanding the curriculum of the project and training them,” she says. “Once that was done, there really was no problem. The more other people learned about it, the more they wanted to do it as well.”
BlueCross BlueShield of Louisiana learned the importance of partnerships and collaborative efforts through this project, says Oliver Reeves. “I don’t think we could be nearly as successful as we were if we didn’t have that in place,” she says.