LifeMasters nursing insurance

For LifeMasters, Nothing Succeeds Like Success.

Here’s an update to a prior post about LifeMasters’ ongoing telephonically-based 11 county Florida disease management pilot program for dually eligible Medicaid beneficiaries with heart failure alone or with coronary artery disease and diabetes. As readers may recall, compared to a control group, there were enough savings to warrant CMS continuing the program. The bottom line intervention vs. control per member per month (PMPM) difference has not been reported yet, but we do know that most of the savings to date appeared to be associated with patients that were successfully engaged by the coach-nurses. As a result, LifeMasters has redoubled its efforts to reach even more patients and enroll enroll enroll. If successful, LifeMasters will deserve credit credit credit and CMS will undoubtedly look to expand the program.

According to a January 29 press release, the push to enroll now includes a ‘Health Network One’ (HN1) physician bounty or a ‘per-member per-month fee for each patient engaged in the program with incremental increases the longer the participant remains in the program.’ HN1 is described here as a Florida company that maintains provider networks for the insurance industry; the Disease Management Care Blog suspects these are private physician practices that rely on HN1 to handle the myriad details behind contracting and credentialing with health insurers. Getting some coin from LifeMasters is one of those details. This is classic win-win: the docs get income and greater buy-in with an otherwise distant vendor, while LifeMasters knows each enrolled patient – thanks to a physician referral - increases the likelihood of success for an already successful program.

The DMCB thinks this is important because of its prediction that disease management, the medical home, pay for performance, insurance benefit design and information technology will continue to evolve to a mutually supportive interlocking Unified Field (or maybe a Teilard de Chardin-esque ‘Omega Point’) of population-based care that collectively make up for the weaknesses of the individual components. We’re already witnessing interest in combined disease management – patient centered medical home approaches, benefit designs that lower barriers to self-care and the use of P4P to support the purchase of EHRs. This is one more example of this trend by a nimble disease management organization taking advantage of the synergies with other population-based care initiatives.

The DMCB suspects the next stage (unless it’s already arrived) will be three-way combinations, such as disease management organizations using P4P to support the medical home or consumer directed health plans that have first dollar coverage of services arranged by medical homes using an electronic record. Then will come 4 and then 5. Interested in knowing which will be the leading disease management vendor in the coming years? One way to do this is look for the program that successfully incorporates all of these concepts.

While LifeMasters and CMS deserve credit, this is ultimately research that is testing an model that is already underway in other settings. That being said, it's clear to most population program architects that, in an open-range, fee-for-service setting, it’s important to get the physicians involved. This is an attractive way to do that, especially if it’s combined with additional IT initiatives like this one and if the physician compensation is tiered and additive. The DMCB knows this because LifeMasters was kind enough to answer an email question about that from the DCMB.

One lingering question remains however: what happens to all that that pay? In an ideal setting, it should be plowed back into the office practice to support even better systems that result in even better performance for even greater pay leading to a virtuous cycle of escalating outcomes. The DMCB suspects that in large salaried physician practices, not all the money makes it to the docs' paychecks. Yet, instead of hiring more personnel or hardware to help garner better performance, the temptation is to use the performance-based revenue for something with an even better ROI - like an ultrasound machine or something. Not that the alternative of diverting all of the money directly to the physicians' pocket is any better. That could happen in an HN1 type of network.

We'll see. In the meantime, the DMCB recommends that disease management programs that get into the P4P arena follow the money.... carefully.