WellPoint State Sponsored Business - Focus on the Future – Reducing Ethnic Disparities

Situation

According to the Centers for Disease Control and Prevention (CDC), diabetes is the sixth leading cause of death in the United States. Researchers from the Harvard School of Public Health note that low health literacy contributes to documented disparities based on race, ethnicity, and access to resources for disease prevention and screening. The American Medical Association defines health literacy as “the ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment”. Also, the presence of ethnic disparities is well documented for diabetes. According to the CDC, the burden of diabetes is greater for certain minority populations, with Blacks and Hispanics nearly two times more likely to have Type 2 diabetes as compared to Whites. Also, the American Diabetes Association (ADA) reports that Blacks and Hispanics have higher rates of diabetes-related retinopathy, which is the leading cause of blindness in the United States.

Solution

WellPoint State Sponsored Business’ Blue Cross of California (Blue Cross) serves an ethnically diverse Medicaid population consisting of over 850,000 members. The ethnicity breakdown for the plan’s current membership population is as follows: 54% are Hispanic, 17% are White, 14% are Asian/Pacific Islander, 12% are Black, 3% are Unknown/Other and <1% are American Indian/Native Alaskan. Recognizing the existence of ethnic disparities related to diabetes care, in 2006 Blue Cross set out to implement a comprehensive diabetic retinal exam (DRE) initiative for its Medicaid population: Focus on the Future - Reducing Ethnic Disparities.

Focus on the Future consists of multi-faceted interventions intended to improve health literacy. In order to be successful, Blue Cross obtained internal assistance from: Medical Operations Management; Medical Directors and Quality Management; Care Management; IT/Data Reporting; Network Support; Marketing and Product Services; and Benefits Administration.

The participation of external stakeholders was also key. Blue Cross obtained assistance from: Primary Care Physicians (PCPs) and Ophthalmologists; Blue Cross’ contacted vender - Vision Service Provider (VSP); and members.

IMPLEMENTATION AND INTERVENTIONS
Diabetes is prevalent in approximately 2.5% of Blue Cross’ Medicaid adult (age 21 and older) population. Focus on the Future targets all Blue Cross Medicaid members enrolled in the health plan’s diabetes disease management program. Blue Cross’s 2006 diabetes program consisted of 19,308 members of which, 50% were Hispanic, 18% were White, 14% were Asian/Pacific Islander, 10% were Black, 7% were Unknown/Other and <1% were American Indian/Native Alaskan.

Prior to implementing Focus on the Future, Blue Cross identified key health literacy issues in members and providers regarding DREs: (1) lack of awareness of the importance of an annual DRE, (2) lack of information to successfully schedule a DRE appointment, (3) Ophthalmologist offices refusing to schedule a member for a DRE without the medical record from the treating physician for the member’s diabetes condition, and (4) Ophthalmologist offices refusing to schedule a DRE for a member due to lack of awareness of Blue Cross’s benefit structure that does not require prior authorization or a PCP referral for a DRE. Based on these identified barriers, to improve members’ and providers’ understanding of the managed care system, Focus on the Future went beyond the provision of member and provider communication and education materials. The interventions detailed in the proceeding sections demonstrate that a concerted effort across an organization is needed in order to effectively address health literacy and narrow the gap of ethnic disparities in health care

Member Interventions:

Intervention	Goal of Intervention
Member DRE Reminders (for diabetics due for their annual DRE)
Biannual DRE reminder packet: includes a message regarding the importance of an annual DRE and a directory of all Blue Cross	1. Enhance DRE education. 2. Simplify the management care process by providing an easy to use tool to locate an Ophthalmologist for a DRE appointment. 3. Improve members' satisfaction with managed care.
Diabetes One Day At A Time Calendar
All diabetics enrolled in the plan's disease management program received a comprehensive diabetes calendar. The month of July in the the calendar was devoted to DRE education, reminders to schedule a DRE appointment appear throughout the calendar, as well as a section devoted to diabetes ethnic disparities.	1. Enhance DRE education. 2. Raise members' awareness about diabetes ethnic disparitites. 3. To provide an easy to use tracking tool for diabetes self-care management.
Member Outreach Calls to Schedule DRE Appointments
Moderate and high-risk diabetics enrolled in the plan's disease management program received an outreach call (English/Spanish) to provide assistance in scheduling a DRE appointment.	1. Improve access to care for DREs. 2. Improve members' satisfaction with managed care. 3. Assist members in navigating through the health care system.
Value-Added Benefit - Annual DRE Coverage
In prior years, a DRE exam was covered every 24 months through VSP benefits. Blue Cross enhanced its Medicaid benefits package to include coverage for a DRE exam every 12 months.	1. Improve access to care for DREs. 2. Provide care according to diabetes clinical practice guidelines. 3. Improve members' satisfaction with managed care.

. Provider Interventions:

Intervention	Goal of Intervention
Removal of Prior Authorization and PCP Referral Requirement for DRE
Ophthalmologists received a reminder notification that Blue Cross Medicaid members do not need a prior authorization or a PCP referral for a DRE exam.	1. Correct inaccurate provider assumptions re: DRE coverage. 2. Improve access to care for DREs. 3. Assist providers in navigating through the managed care system. 4.Improve members' and providers' satisfaction with managed care.
Annual PCP Diabetes Member-Specific Diabetes Profile
PCPs received member-specific diabetes profiles based on 12-months of medical and pharmacy claims data. The date or lack thereof for a DRE for a member is indicated on the notification.	1. Assist PCPs in identifying who needs an annual DRE. 2. Provide care according to diabetes clinical practice guidelines.
Coordination of Medical Record Transfer/Sharing
Opthamologist offices sometimes refuse to schedule an appointment for a DRE unless the member's medical record at the PCP office has already been sent to the Opthamologist.	1. Imrpove access to care for DREs. 2. Assist providers in navigating through the managed care system. 3. Improve members' and providers' satisfaction with managed care.

Better Health Lower Costs

To evaluate the effectiveness of Focus on the Future, Blue Cross analyzed DRE claims to determine the change in DRE rates for each ethnic group in 2006 as compared to 2005. The 2005 diabetes program members were considered the ‘control group’ because DRE interventions in 2005 were minimal. Whereas, the Focus on the Future DRE interventions in 2006 (‘comparison group’) were extensive. Blue Cross used the CPT procedure codes and ICD-9 surgical codes indicated by HEDIS® specifications for identification of a DRE. DRE claims analyzed were based on members enrolled in the plan’s diabetes disease management program during the measurement periods: 2005 = 13,309 members and 2006 = 19,308 members. For each measurement period, a maximum of one DRE claim per member was counted toward the analysis.

Better Health

In comparison to 2005, the 2006 data indicates a significant (p<0.05) increase in the percent of members receiving a DRE and reduced disparities among the ethnic groups of Black, Hispanic, White and Other/Unknown (Figure 1).



With all ethnic groups showing increased DRE rates in 2006, the results suggest the interventions for the Focus on the Future improved members’ access to and initiation of diabetes care. By raising awareness about the importance of a DRE and the plan’s coverage of an annual DRE, as well as the implementation of modified communication strategies to members and providers, the Focus on the Future helped to reduce and/or eliminate barriers to diabetes care previously experienced by members. Through the Focus on the Future, Blue Cross learned that addressing health literacy with both members and providers may lead to increased comprehension and initiation of preventative care, as well as an improved trusted relationship between the member and provider with the managed care plan.

Lower Costs

From a cost-impact perspective, in a study by the Lewin Group for the ADA, estimated costs for diabetes in the United States totaled $132 billion, with $92 billion belonging to direct medical costs for diabetes and $40 billion belonging to indirect costs. Undoubtedly, a portion of the costs associated with diabetes stems from eye-diseases such as retinopathy, cataract, and glaucoma. Diabetes-related eye diseases are preventable in many cases through early detection by way of a DRE. The potential to reduce diabetes-related eye complications by receiving an annual DRE underscores the importance of Blue Cross’s Focus on the Future, which was shown to successfully increase the DRE rate among ethnic groups. Notably, the statistically significant increases observed for the Black and Hispanic ethnic groups translate to a narrowing of ethnic disparity in diabetes care for populations shown to be at higher risk for diabetes-related complications.