Osteoarthritis: Health Insurance Perspective
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- Krakauer, R. HSS Jrnl (2012) 8: 70. doi:10.1007/s11420-011-9233-0
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Health care costs for members with osteoarthritis have been estimated as twice the cost of a random population, controlling for comorbid conditions. This population generates approximately 5% of the medical cost of a health plan. As such, patients with osteoarthritis provide opportunity to improve outcomes and are candidates for medical management.
The goals of medical management are improvement in the quality of health care and a reduction in its cost—preferably both simultaneously. Opportunities in osteoarthritis include assurance of a reasonable and appropriate medical plan, support, and education of the patient to promote adherence, reduction of adverse events and drug reactions, and concurrent management of comorbidities and psychosocial barriers. Several domains of effort are available.
Precertification and Concurrent Review
The goal of this effort is to assure that the most appropriate treatment is provided for the patient at the most appropriate time and setting. This might include review of plans for viscosupplementation, lavage, acupuncture, medications, and surgery based on well-established and evidence-based guidelines.
Case Management or Disease Management
Case or disease management should provide individual members with specific assessment and planning. Ideally this would involve identification of a case with opportunity, a comprehensive assessment of the case including all clinical conditions and psychosocial barriers including a depression screen, and a comprehensive plan to support the member to help promote optimal outcome. In Aetna’s Medicare Advantage population, about 19% are in case management or disease management, which results in a 31% reduction in acute inpatient days compared to unmanaged Medicare on a risk-adjusted, geographically matched basis. In our Medicare Advantage program, this alone represents a cost reduction of $116 per member per month. We would consider such days that “don’t happen” an example of management at the intersection of quality and cost.
Wellness and Prevention Programs
These programs attempt to engage members to promote health and prevent a condition from developing or progressing. For example, Aetna’s hypertension program provides monitoring and support blood pressure management and results in an 18% conversion from inadequate to adequate control. In the case of osteoarthritis, case managers engage members to provide support and facilitate adherence to medical regimens and exercise programs, identify issues with gaps in care that can be identified through claims (such as adverse drug interactions), and facilitate the management of comorbid conditions and psychosocial barriers.
With the use of these domains, opportunities exist to identify and engage persons with osteoarthritis to improve outcomes and favorably impact health care quality and cost. An example might be our program for members with advanced illness, where we have demonstrated dramatic impact on quality and cost, including an 82% reduction in acute inpatient days, through case management . Aetna and other health care insurance providers seek help from physicians and other provider partners to help identify and realize such opportunities .
The author acknowledges that he is an employee of Aetna and is a stockholder of that company.