1. From Wellness to
Disease Management:
Covering the Health
Care Continuum

2. Reality Check
• The top three causes of death are heart disease, cancer
and stroke; The leading cause of all three is. A.) High
Blood Pressure B.) Fatigue C.) Obesity
• The director of the Behavioral Medicine Research Center
at Baylor College predicts what percentage of Americans
will be overweight or obese by 2040. A.) 50% B.) 90%
C.) 75%
• What percentage of US adults do not engage in any
leisure time physical activity. A.) 40% B.) 25% C.) 60%
(Department of Health and Human Services)
• An American Cancer Society report shows obesity and
lack of physical activity causes how many cancer cases in
the United States? A.) 1/5 B.)1/2 C.) 1/3

3. For Every 100 Employees…

4. 60 are Sedentary

5. 25 Smoke

6. 64 are Obese/Overweight

7. 27 Have Heart
Disease

8. 10 Have Diabetes

9. 50 Have High
Cholesterol

10. 24 Have High Blood
Pressure

11. 50 Are Distressed or
Depressed

12. Reducing one health risk can…
•Reduce absenteeism by 2%
•Improve productivity by 9%
Reference: Pelletier B, Boles M, Lynch W. (2004). Change in health risks and work
productivity over time. J Occup Environ Med.
Small changes, Big
Impact

13. Activation!
 Our level of personal activation (“Take
Chargedness”) determines our behavior,
our risks, our likelihood to change, and
our medical costs.
• Diet
• Exercise
• Disease specific self-management
• Consumeristic behaviors

14. 70%
46%
35%
21%
15%
12% 10%
Depression Stress Blood
Sugar
Control
Overw eight Smoking Blood
Pressure
Sedentary
Lifestyle
Increased health risk, increased cost
Impact of Modifiable Risk Factors on
Medical Expenses
Adapted from Goetzel RZ, Anderson DR, Whitmer RW, et al, Journal of Occupational and Environmental Medicine (40) (10) October 1998, 1-12
Annualadjustedmedicalexpenses
ie. Overweight individuals cost
21% more than those whose
weight is in the healthy range

15. Care Management: Every Day
Health
CareEnhance Health Coach Special Beginnings
Disease Management
Case Management
SUPPORT FOR EVERY DAY HEALTH
WELLNESS COACHING SUPPORT MANAGEMENT
 Integration between systems, people, programs
 Lifelong support for members at any health stage
 Simplification for member, employer, physician
 Transformation of health care system

16. CareEnhance: Decision
Support
The difference between…wondering what to do and knowing.

17. CareEnhance: Decision
Support
 24/7 toll-free phone access to registered nurses
• 5 call centers and support for more than 100 languages
 Help knowing when, where (or whether) to seek care
 Library of over 1,100 prerecorded health topics
 Program reminders mailed to members quarterly
 Administered by McKesson Health Solutions
.

18. Health Coach: Lifestyle
Change
The difference between…inaction and taking charge.

19. Special Beginnings: Healthy
Pregnancy
The difference between…worry and peace of mind.

20. Special Beginnings: Healthy
Pregnancy
Nurses provide one-on-one member
support
• Assess each member’s risk to determine education and outreach
• Member’s choice of pregnancy book or DVD (Spanish options)
• What to expect during pregnancy and birth
• Signs of premature labor and other complications
• Tailored pregnancy information
• 24/7 phone access (CareEnhance after hours)
Engine rewards for completing program

21. Case Management: Advocate,
Navigate
The difference between…
going it alone and having a trusted advisor help you through.

22. Case Management: Advocate,
Navigate
 Support for serious illness or injury
 One-on-one nurse support based on conditions
• Nurses advocate, navigate and coordinate care
• Promote optimal quality
• Match resources to needs
 Avert unnecessary expenses ($20 million in
2005)
• 1% of members drive 30% of health care costs
Reminder: Case managers can help members
understand their conditions, work with multiple
providers and make the most of their benefits.

23. Disease Management: Change
the Future
The difference between…
an existence controlled by
your condition and taking
control of your life.

24. Disease Management: Change
the Future
 Targets diabetes, cardiac, and respiratory
conditions
• AdviCare packages may cover additional conditions
 Prevent or postpone complications
 Nurses and clinicians offer one-on-one support
• Interventions based on members’ risk level
• Newsletters, care reminders, phone contact, other outreach
• Support treatment plans and improve compliance
• Improved clinical measures and outcomes
• Help members understand and manage their condition(s)

25. Disease Management: Change
the Future
 Disease management is the difference between...
BEFORE
Uncontrolled Diabetic with Non-Healing Wound
3 Office Visits $ 375
Hospital Admission $25,000
Surgeon Fees $ 6,000
Prosthetic $12,000
Rehabilitation $24,000
Insulin $ 6,000
TOTAL $73,375
AFTER
Controlled Diabetic
6 Office Visits $ 750
Foot Care $1,100
Dietician $ 300
Physical Therapy $ 500
Insulin $4,500
Pharmacy Services $ 110
TOTAL $7,260

26. Why Regence Disease
Management Matters
 45% of members with chronic conditions
do not receive evidence-based care*
• Medications, tests and exams, doctor visits
• Improve diet and exercise
• Reduce stress
 Engaged members make better health care decisions
 Improvements in quality of life may
• Increase productivity
• Reduce absenteeism and presenteeism
• Slow cost trends over time
• *Source: McGlynn, et al., New England Journal of Medicine, 2003.

27. Regence Disease Management
Basics
 Targeted conditions
• Diabetes
• Coronary artery disease (CAD)
• Congestive heart failure (CHF)
• Asthma
• Chronic obstructive pulmonary disease (COPD)
• Depression
• Anxiety
 Prevents or postpones complications
 Supports treatment plans and improves compliance
 Helps members understand and manage their condition

28. Health Care Advocacy for Members

29. Having A Chronic Illness Is
Complicated
Only about 20% of people with health conditions do what they
should to maintain good health
Take Medications
Do Prescribed Tests Visit Doctor Regularly
Reduce Stress
ExerciseFollow Diet

30. Physicians Have Challenges, Too
 Health care systems have driven
physicians to “fix” patients, not
maintain their health
 Lack of time with patients
 Increasing prevalence of chronic
conditions
 Shift to short term episodes rather
than long term health status.
Our goal is to support the physician with patient
behaviors between office visits

31. We Stratify the Population
 Stratification of Risk
•Rules-based algorithms
•Individually stratifies the population so
we know where to start
Low Risk
High Risk

32. We Apply the Right Level of Intervention
 4 levels of risk stratification
 Program tailored to risk level
 Fluid stratification algorithms (claims,
prescriptions, updates, self report, physician and
care calls)
 Interventions based on member specific needs and
best practice guidelines
Level of intervention is based on individual stratification
and risk status of the member

33. What do members participating in
the program receive?
AdviCare participants will be
offered:
 One-on-one nurse-based counseling
 Support through telephone calls
designed to help the member through
coaching and education
Members talk by phone with a
knowledgeable
RN who:
One-on-one nurse-based counseling
Understands the complexities of their conditions
Can take the time to answer all of their questions
Has access to a variety of educational materials

34. We Address the Whole Person
 It’s about people, not the
disease
 Understand individual
behaviors and help the
participant modify them
 In order to create change
you must establish
unconditional credibility
and positive intent
 Set goals with the patient
that are achievable
 Build on their successes
All co-morbidities and behaviors must be managed
simultaneously by the same trusted relationship

35. We Extend the Physician’s Reach
 Expanded “interventions” between
office visits
 Comprehensive health condition
protocols (evidence based
standards of care)
 Behavioral modification
 In market nurses supporting
practice patterns with tools and
education
A primary goal of our program is to support the physician
with patient behaviors between office visits

36. Outcomes Reporting
 Financial – semi-annual report reflects pre-
versus post program results
 Clinical Outcomes – semi-annual report on
members’ overall compliance with selected
standards of care
 Utilization – semi-annual with % change in
admissions, length of stay, ER visits and bed days
 Member Satisfaction - annually
 Activity – quarterly report showing members
counts and type/frequency of member contact
 Note: Client level reporting varies based on
group size.

37. Health Care Cost for Diabetes Population Declined During Years 1 and 2 both
in Real Terms and when Compared to Adjusted Base Period Costs
Year 1 Trend is 7%
Year 2 Trend is 12%
Program Results

38. Diabetes Clinical Indicator
Improvement

39. Results
• 43,492 Program participants
• 677,940 Educational mailings
• 186,088 Telephonic interventions
Office Visits
ALOS (days)
ER visits
Admissions
Bed Days
Utilization
Other
Professional
Pharmacy
Outpatient
Inpatient
Overall Costs
6.56
6.0
263
157
938
$45
$97
$106
$58
$145
$431
Intervention
6.93
5.2
307
206
1,061
$47
$137
$118
$118
$147
$551
No Intervention
-5%
13%
-14%
-24%
-12%
-4%
-29%
-10%
-51%
-2%
-22%
% Change

40. Member Satisfaction
Percent of Members Rating
the Program Good to Excellent
Member satisfaction with healthcare increases steadily
so you hear less noise.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Used AdviCare Suggestions
& Guidelines
Satisfied with Courtesy &
Sensitivity of AdviCare
Nurses
Overall Satisfaction with
AdviCare
78%
89%
78%

41. Success Story
 Diagnosed with type 2 diabetes for over a decade.
 During a Welcome Call, she told the AdviCare nurse
that upon receiving her AdviCare diabetes
workbook,she read it from "cover to cover." She
stated more than once how pleased she was with it;
in comparing it with others she had read, she found
AdviCare's to be "more readable" and to contain
"better dietary information" than others she had read.
She reported that despite her long time diagnosis,
she looked forward to participating in the AdviCare
program.

42. Making a Difference in
Someone’s Life
 A member had a history of substance abuse and uncontrolled
diabetes prior to her calls from the AdviCare program. For four
years she had not been having regular laboratory testing or
reviews of her medications. In 2005, the AdviCare nurses sent
her workbooks and encouraged the member to review the
standards of care. The member also set a goal to call member
services and find a physician to help her manage her diabetes.
Since then the member has had her medications reviewed, her
annual exams, and A1C testing. She has continued to remain
sober and stated she attributes her current health with diabetes
to the information and support provided by the AdviCare
nurses.

43. Thank you for attending…
Jennifer Havlin, BA, BSN, RN
Regence BlueShield
(206) 332-5011
jxhavli@regence.com