Carena Mobile Medicine

Implemented by The Microsoft Corporation

Challenge | Solution | ROI | Time Investment | Lessons Learned | Future Changes

Challenge

Microsoft is a self-insured employer. The average cost of an Emergency Room (ER) visit for Microsoft enrollees in the US increased by 66% from 2003 – 2006, with 15 – 20% of conditions driving 80% of the costs. In reviewing claims information, it was determined that only 20 – 30% of ER visits for Microsoft enrollees were clearly for emergent conditions. In an effort to address this issue without using more a typical industry approach (i.e. co-pays) and pioneer an innovative solution, on April 2, 2006, Microsoft introduced the Mobile Medicine program (as a pilot). The intent of Mobile Medicine program, a modern day house-call service, was to reduce costs through the replacement (and avoidance) of unnecessary ER visits and substitute those visits with more appropriate care. Microsoft also wanted to improve patient outcomes through education and referrals, ensure enrollees had a primary care physician, and promote Microsoft’s other benefit and wellness programs.

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Solution

The Microsoft Mobile Medicine program, in partnership with Carena Inc. and its medical group, provides in-home medical treatment from a physician 24-hours a day, 7 days per week for urgent, non life-threatening medical situations. The program is available to all members of the Microsoft enrollees living in the Puget Sound area. Microsoft’s membership in the Puget Sound has grown from 80,000 when the service was first implemented to approximately 98,000 as of May 2009 and we have recently delivered our 10,000 house call. (This program is now considered an established program and is no longer considered a pilot effort.)

To access the program, the member calls the 24-Hour Health Line and their health situation is triaged by a registered nurse. Depending on the member’s condition, the nurse may recommend self-care options, suggest that the member call their doctor to discuss their condition, or recommend care in the ER. If the nurse's assessment indicates that the health issue is urgent, but not life-threatening, the nurse may recommend the Mobile Medicine program.

If the Mobile Medicine program is recommended, the nurse sends an efax to Carena’s Patient Care Coordinator (PCC) and a doctor is dispatched. The doctor calls each member before the visit to assess the member’s concern, which also may result in self-care options or a referral to the ER. If the doctor confirms that a home visit is appropriate, the doctor will set expectations with the member of an arrival time based on the acuity of the member’s medical condition and the number of members in the queue. Typically the physician arrives at the home within 1-2 hours.

Once they arrive, the doctor addresses the member’s acute issue, conducts a full health history (electronically) and takes the opportunity during this ‘teaching and learning moment’ to educate the member on managing any underlying health issues (either known or something determined during the visit). The member is also referred to appropriate Microsoft Wellness programs such as Smoking Cessation, EAP, Ergonomics, Disease Management, Weight Management program, etc., based on their individual situation. Our experience shows that approximately 15% of members who have a Mobile Medicine visit do not have an established Primary Care Physician (PCP) so for these situations, the doctor assists the member in identifying a PCP and even helps coordinate the initial appointment. All medical chart information and notes from the home visit are sent to the PCP and are also available to the member to keep and/or add to their Microsoft Health Vault account. Visits occur in the home (away from Microsoft work facility). The average visit lasts one hour.

A rapid-response flu initiative was introduced in 2008 since early intervention and treatment of the flu can reduce the length of the illness. During flu season, if the nurse detects two of three flu symptoms (fever, cough or body aches) during triage, a home visit may occur. The process is the same as described above with the addition of the prescribing of antiviral medication for the patient and family members to prevent the spread of the virus.

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Return on Investment

The program has grown in size from 80,000 members when full implementation occurred in January 2007 to almost 100,000 members and to date Microsoft has achieved the following results:

• As of June 1, 2009, 10,000 visits have been delivered
• The average cost of a Mobile Medicine home visit is 40% less than the average cost of an ER visit for Microsoft
• Microsoft measures savings of this program in terms of 1:1 replacement cost of ER visits, and our savings in calendar year 2008 was approximately $1M.
• Microsoft members who are using the program tend to have underlying health conditions. Once a Mobile Medicine visit occurs, their ER utilization and healthcare claims costs have decreased.
• Inpatient hospitalization claims have decreased for those using the program.
• Calls to the 24-Hour Health Line (on average) have increased by 55% as a result of the program and typically double during peak times (cold and flu season). Members who have access to the program are 27% more likely to call the 24-hour Health Line than the Microsoft membership population as a whole.
• 41% of members who received a home visit were referred to other Microsoft health and wellness programs such as smoking cessation, EAP, weight management, disease management, ergonomics, etc.

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Time Investment

Initial Planning.  The development of the concept spanned approximately six months and then the planning process for the Mobile Medicine launch required about four months. The planning effort included finalizing plan design, establishing pricing, contracting, communications, and an implementation and readiness strategy. A core team of four Microsoft US Benefits employees spent more than 50% of their time on this project in the months leading up to launch day. Additional members of the project team included Carena (known then as On-Site Docs), Premera Blue Cross (TPA), Evergreen Healthline (Health Line vendor), and several other groups within Microsoft including tax, legal, risk management and the broker partner.

Pilot.  The pilot launched in 2006 in four phases using zip codes to delineate the service areas, and it was initially rolled out to 5400 members including all members of the HR organization in the Puget Sound area. Phase 2 of the program was rolled out July 1, 2006 with an additional 16,000 members. Phase 3 occurred September 1, 2006 with an additional 17,000 members and the final phase, Phase 4, occurred January 1, 2007 covering about 97% of the Puget Sound area or approximately 80,000 members total.

Post Implementation.  Once implemented, weekly meetings with the key stakeholders took place for the initial 6 months. Meetings were then reduced to bi-weekly discussions and eventually monthly within the first year. The original core team involved in the roll-out of the program was reduced to a single Program Manager within the first six months. Reporting is tracked and monitored weekly. Opportunities to promote and/or integrate information on other Microsoft benefit programs and/or strategies are regularly evaluated and implemented. The flu initiative is a good example of this.

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Lessons Learned

• Regular communications and promotion of the program and its entry point (the 24-Hour Health Line) are critical to utilization. Microsoft members are regularly reminded of the services, therefore incenting them to call the 24-Hour Health Line when they have a health concern. Without these reminders and prompts, utilization declines (and “old habits” of accessing the emergency room for non-critical care resurface).
  • Developing and implementing a reoccurring communication strategy is key (and takes time to plan). Areas of focus for each communication piece may change depending on the trend of health concerns of the members.
• An early concern was that inappropriate and over utilization of this service would occur (which is in part why the Health Line is used as the ‘gatekeeper’. In analyzing our experience, these concerns turned out to be unwarranted, and our overly strict access controls unnecessarily prevented some from receiving the services. We now recognized that employees understand the value and intent of the program and that the triage guidelines initially used by the nurses were too stringent.
• Strong integration and partnership with the entry point (i.e. 24-Hour Health Line) is critical to program success. This type of program requires flexibility from the health line partner in terms of adjusting their systems and processes, ensuring appropriate referrals to the house-call program, and preserving a positive employee experience (even when they have to say “no” to a house-call request).
• Strong partnership with the TPA was also critical in terms of some of the unique billing codes that need to be established.
• When establishing initial reporting data elements, no detail is too small (i.e. time of day, day of week, etc). Gathering and analyzing that information helped ensure appropriate modifications were made for best outcomes. As we gained more experience with the program, some of the original data elements were removed/changed with the focus more on YOY trends vs MOM one-offs.
• In order to offer a 24/7 service 365 days per year, a sufficiently large concentration of participants in a manageable geographic area is needed. Microsoft was able to offer this service to our employees and their dependents in the Puget Sound area because of the number of high number of eligible participants in a fairly concentrated geographic area (~100,000). Microsoft continues to explore ways of expanding this service to other parts of the country where there are large groups of employees (1000+). However, we’ve determined that these numbers are insufficient to sustain a 24/7 service (such as in Microsoft’s TX, NC and ND locations) or a in a more dispersed population with challenging traffic patterns (such as in the Silicon Valley). One solution would be to partner with other employers to build out a larger client base in these areas.
• The phased implementation and introducing it as a pilot provided Microsoft the opportunity to make modifications to the program and related processes as we gained more information and experience. Data gathering and regular feedback was critical as we were able to identify gaps or things that weren’t working and quickly take steps to correct them.

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How We Would Modify the Process in the Future

• There needs to be a concentration of members within a specific geographic region to support the model. Smaller membership populations that have strong health line utilization or a coalition of employers may provide enough critical mass to support the model.
• This type of program requires a benefit plan design that would support and encourage members to use the service (i.e. it is less expensive or equal to the cost of ER or other services).