Statement of Bruce Weiss, M.D., M.P.H., Chief Medical Officer,
AvMed Health Plan, Gainesville, Florida

Testimony Before the Subcommittee on Health
of the House Committee on Ways and Means

Hearing on the Medicare+Choice: Lessons for Reform

May 1, 2001

I appreciate the opportunity to participate in today's hearing and to describe the nature and scope of disease management programs in managed care plans and specifically the disease management programs my plan offers to all our members, especially our Medicare members. Disease management programs are one of the major enhancements over traditional FFS Medicare that Medicare beneficiaries receive by enrolling in a Medicare+ Choice option--from the newest PSO to the largest HMO. These programs are important elements of every Medicare managed care option--providing coordination of care, promotion of best practices and patient empowerment through education.

Disease Management Programs

Let me explain the process we use to implement disease management programs. First, our goals are to:

· empower our members through education;

· provide our members and health care providers with tools to improve our members' quality of life and promote preventive lifestyle choices; and

· facilitate a comprehensive and integrated health care delivery team concept to assure the best clinical and economic outcomes.

To achieve these goals, we have developed a strategy that involves:

· identifying the high-risk population;

· implementing and promoting national guidelines;

· implementing critical pathways;

· promoting effective client self-directed interventions;

· designing and implementing comprehensive case management and home health interventions;

· promoting safe and effective physician intervention; and

· measuring outcomes.

We implement this strategy using an integrated approach among health care professionals. Care coordinators serve as the liaison between members and health care providers, coordinating care and services while also performing educational and patient advocacy roles. Health care providers deliver treatment plans according to accepted "best practice" guidelines, while assisting with the coordination of care and providing continuous feedback on results. Home health care is also an important component of many disease management programs.

We evaluate our disease management programs using measures that focus on patient satisfaction and clinical outcomes, as well as performance indicators developed by the NCQA. These programs have been particularly important to our senior population in Medicare+Choice.

Numerous studies have demonstrated that well-designed disease management programs can have a significant impact on participants' well-being and overall health status. Patients with moderate to severe Congestive Heart Failure have been documented to improve their functional status through a CHF disease management program. This means that patients who were essentially home- or bed-bound can get out and go to church, shop or visit friends--a major improvement in their quality of life.

At AvMed we have 8 care or disease management programs--6 focusing on the illnesses of our Medicare beneficiaries: Congestive Heart Failure (CHF); Diabetes; End Stage Renal Disease (ESRD); Chronic Wounds; and Chronic Obstructive Pulmonary Disease (COPD). All of these programs require an investment in staff, materials and information systems to be successful. Nurses regularly call members to assess their progress. Patients who appear not to be improving are referred to their primary care physicians or specialists for assessment and modification of their treatment.

With care management, medical problems are identified and addressed earlier, avoiding potential risk to the patients, hospitalizations and medical costs. AvMed and others are looking at new technology that will allow us to more efficiently monitor larger numbers of patients, with lower administrative costs. Today we have a pilot program in which each morning our members step on an electronic scale, which weighs the member, asks several key clinical questions and then electronically transfers this information to AvMed. Those members reporting worsening symptoms or weight gain above limits set by their physicians are contacted by one of our nurses. In addition, this daily information is available to the members' treating physicians in a summary form for on-going use in managing their care.

It is through on-going investments such as these, that disease management programs are going to reach their full potential and be expanded to a larger patient base. However, these population-based programs are expensive, require staff and expertise that is generally not available in most physician offices and is not reimbursable under most FFS plans.

To illustrate, I want to share the experience of one of our members with you. Mrs. "B" is a delightful 80 year-old North Florida Medicare beneficiary who joined AvMed in February 2000 and was enrolled in our Congestive Heart Failure Program due to heart damage caused by her diabetes. Last July her husband died from lung cancer. In January, she fell and developed cellulitis, a serious infection of her leg, for which she was given oral antibiotics. Shortly thereafter, she called our Healthy Heart Hotline because her heart symptoms worsened and she had increased difficulty breathing. Mrs. B had stopped taking her antibiotic for her leg problem, because it was making her swell up. Our nurse contacted her physician who called her and instructed her to resume her antibiotic. A home health nurse was also sent to her home and found that she had gained over 5 pounds, and that she was only taking half the dose of her diuretic/water pill. An intravenous dose of a diuretic was given. During follow up visits, it was noted that Mrs. B's blood sugar was over 350 mg/dl and that she had not been taking her insulin since her husband's death--he was the one who gave her insulin injections.

Arrangements were made for Mrs. B and her daughter, also a diabetic, to be seen by her physician in his office and both were instructed on administering insulin, following a diet and exercising. Since this visit, Mrs. B has moved in with her daughter and both have become more compliant with their diets, managing their diabetes and exercising.

Issues Facing the Medicare+Choice Program

The future success of the Congestive Heart Failure Program--and other innovative disease management programs offered by AvMed and other Medicare+Choice plans--depends on the long-term stability of the Medicare+Choice program. As effective as Medicare+Choice plans are at using disease management strategies to improve health care quality for Medicare beneficiaries, we cannot succeed without adequate funding and a sensible regulatory environment.

This hearing's focus on administrative and regulatory issues is highly appropriate, given the reality that the costs of Medicare's many regulatory requirements are rarely measured in comparison to their benefits. This forces health plans to spend scarce resources on compliance activities of questionable value and, as a result, leaves plans with fewer resources to spend on disease management initiatives.

Payment and regulatory requirements dictate the environment in which Medicare+Choice plans operate. The current payment and regulatory environment has forced many plans to make difficult decisions regarding their participation in the Medicare+Choice program. We are deeply concerned that the administrative and regulatory actions taken by the Health Care Financing Administration (HCFA), together with the unintended results of the Medicare+Choice payment formula, have undermined the program's stability. Rather than enjoying expanded coverage choices as planned under the Balanced Budget Act of 1997 (BBA), many beneficiaries face fewer coverage choices today.

Regrettably, this loss of choices means that fewer Medicare beneficiaries have access to the high quality health care services that are delivered through the disease management programs that AvMed and other Medicare+Choice plans are implementing. Ideally, all Medicare beneficiaries should have access to these services. In recent years, however, hundreds of thousands of beneficiaries have been forced to give up their Medicare+Choice plans and enroll in the old-style fee-for-service Medicare program.

Restoring these choices and stabilizing the Medicare+Choice program should be Congress' top priority in the 2001 Medicare debate. Medicare+Choice has the potential to serve as a foundation for the Medicare program of the future.

As the Administration and Congress consider options for stabilizing the Medicare+Choice program and pursuing structural reforms in the Medicare program, it is critically important to ensure that Medicare is administered efficiently and effectively. The regulatory framework should be designed to promote, rather than impede, the implementation of disease management programs that improve health care quality for Medicare beneficiaries.

Again, I thank you for the opportunity to briefly share with you some information regarding the exciting opportunities surrounding disease management.