SECTION CONTENTS:

The Way of the Future
Centers for Medicare & Medicaid Services (CMS)
Performance Assessments
Pay-for-Performance
Disease Management (DM)

The Way of the Future

Although the US health care system has not historically taken a systematic approach to the health care of its citizens, there has been more of an effort in recent years for its various components – insurers, health care institutions, employers, individual practitioners, the government and others – to take a systems-based approach to handling some chronic diseases, most notably, cardiac disease, asthma and diabetes.

The most recent chronic disease to be considered optimal for a systematic approach is bone disease. Systems-based approaches to the prevention and treatment of osteoporosis can be exceptionally valuable both in improving osteoporosis management care and in reducing adverse outcomes from poor bone health. This type of approach can help to overcome the problems created by poor communication and a lack of collaboration among the various components of the health care system.

Systems-Based Activities

• Identifying various risk levels of the population and developing intervention strategies for those at risk
• Educating clinicians and the public about bone disease
• Offering appropriate preventive, diagnostic and treatment services to those at risk
• Evaluating bone health outcomes within the population group

The underlying attitudinal change necessary for a “systems-based” approach is that all facets of the health care system must be willing to go beyond the traditional role of simply treating bone-related problems or symptoms and move toward developing strategies for improving overall bone health and preventing future fractures. Health plans and insurers can apply a “systems-based” approach to prevention and care of osteoporosis and low bone mass with a few formal policies, procedures or guidelines.

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Centers for Medicare & Medicaid Services (CMS)

CMS currently requires all Medicare Advantage plans to annually report on their clinical performance using HEDIS measures, and there is currently a lobby to integrate a pay for performance program around this reporting. (NCQA News) Medicare sets the standards for most private sector coverage in terms of bone health:

• Under a provision of the 1997 Balanced Budget Act, Medicare covers BMD testing (radiologic, radioisotopic or other FDA-approved procedures) every 2 years for people with or at risk for osteoporosis.
• The Medicare Modernization Act of 2003 gives beneficiaries access to some level of coverage for medications that treat bone disorders.
• Medicare covers physical therapy for certain diagnoses related to falls, but not for those at risk for falls.

While improved bone health clearly benefits everyone in the health care system, progress can be made only with the cooperation and commitment of health plans and insurers. Some have played a limited role in promoting optimal bone health because of a reluctance to invest today in preventive services that might not demonstrate clinical or financial benefits for several years – perhaps not until those patients who have received the services have become eligible for Medicare.

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Both the federal government and private insurers can use the diagnostic and utilization data to assess how well the disease is being managed. While such performance management techniques have not yet been applied regularly with osteoporosis as with other chronic diseases, the National Committee for Quality Assurance (NCQA) introduced a performance measure for osteoporosis in 2004. This, combined with the federal government’s emphasis on bone health, as evidenced by the 2004 Surgeon General’s Report, is likely to elevate the incidence and importance of osteoporosis disease management.

NCQA & HEDIS

Since its inception in 1990, the National Committee for Quality Assurance (NCQA) has been the leader in health care quality assessment. NCQA’s strategies have helped drive quality improvement at multiple levels of the health care system. Through its accreditation and certification programs and HEDIS (the Health Plan Employer Data and Information Set), NCQA is able to publicly report information that enables consumers and health care purchasers to make more informed decisions.

HEDIS, a set of standardized performance measures, provides reliable comparisons of the performance of managed health care plans. It also serves to:

• Provide a standardized consumer survey that evaluates plan performance in areas such as customer service, access to care and claims processing
• Help health plans and insurers measure performance of care and service using over 60 different measures to identify where to focus improvement efforts
• Supply CMS with an assessment of Medicare Advantage plans

HEDIS Osteoporosis Measure

Working with a group of experts, the NCQA studied the demonstrable financial and quality-of-life improvements of osteoporosis management. Results showed:

• Treatment of osteoporosis reduces the risk of subsequent fractures by 40-60 percent
• Proper management of osteoporotic fractures will reduce disability, hospitalizations and mortality associated with them.

In 2004, the first osteoporosis-specific HEDIS performance measure went into effect for Medicare managed care plans, defined as:

“The percentage of women age 67 or older who suffer a fracture who received either a BMD test or prescription treatment for osteoporosis within 6 months of the date of the fracture.”

This should be the standard of care in best practice for treatment and management of women with fractures. NCQA is continuing to explore other measures that will improve the care of patients who have osteoporosis.

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Pay-for-Performance

Reimbursement policies represent one of the most innovative ways that health plans and insurers can promote quality and quality improvement. According to NCQA, pay-for-performance programs in the private sector have led to substantial quality improvements and cost savings of between 10 and 15 percent. Because of the prevalence, expense, and quality-of-life issues associated with low bone mass, osteoporosis is ideal for pay-for-performance initiatives from both medical and financial perspectives.

NCQA currently offers “Physician Recognition” programs that serve as the foundation for various pay-for-performance efforts at the physician level.

• Together with the American Diabetes Association and the American Heart Association/American Stroke Association, NCQA offers programs that highlight doctors who provide diabetes, cardiac and stroke care that is consistent with evidence-based standards.
• The employer-led Bridges to Excellence program and many health plans offer financial incentives to doctors who meet the NCQA criteria in these areas.

NCQA and the Medicare Payment Advisory Committee (MedPAC) strongly support broad implementation of pay-for-performance at all levels of the Medicare system, including Medicare Advantage health plans, medical groups, hospitals, and doctors. Congress is currently considering the adoption of pay-for-performance programs to be incorporated into Medicare.

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Given the high cost of osteoporotic fractures both in terms of health and dollars, disease management (DM) programs for osteoporosis can make the connections necessary to reduce the impact of fracture on our nation’s health care system. It may be possible for osteoporosis DM programs to be integrated into similar types of programs for other chronic diseases such as diabetes, heart failure and asthma.

Experts state that for any DM program to be effective, it should be simple and user-friendly. According to the Disease Management Association of America (DMAA), DM is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.

Disease management:

• Supports the physician or practitioner/patient relationship and plan of care
• Emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies
• Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.

Full-Service Disease Management Programs include: (Programs consisting of fewer components are Disease Management Support Services)

• Population identification processes
• Evidence-based practice guidelines
• Collaborative practice models to include physicians and support-service providers
• Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance)
• Process and outcomes measurement, evaluation, and management
• Routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers, and practice profiling)

The NCQA accreditation of DM programs lends credibility to the managed care organizations that support these quality improvement initiatives. NCQA conducts a rigorous review of each DM program prior to accreditation with the focus on:

• Program content
• Patient services
• Practitioner services
• Clinical systems
• Measurement and quality improvement
• Program operations

DM Roles and Responsibilities

Insurers:
Health plans and insurers can assess and monitor the performance of their providers; establish quality-improvement programs; and consider incentives to the providers with the best outcomes.

Clinicians:
The most important role for the caregivers in a systems-based or DM approach to bone health is to educate themselves and their patients about prevention, risk factors, screening, diagnosis and treatment.

Patients and families:
Individuals must assume personal responsibility for educating themselves about bone health, understanding that it is a lifelong issue and that osteoporosis is not just a women’s disease. People must make a lifelong commitment to proper nutrition, exercise and whatever else is needed to maintain strong bones.

Hospitals:
Hospitals and rehabilitation facilities can take a more long-range approach by trying to ensure that after the patient has been discharged and the fracture has healed, strategies are in place to improve the individual’s overall bone health and to prevent future falls.

Nursing homes:
Skilled nursing facilities can establish measures to prevent falls and fractures, make sure their patients receive appropriate amounts of calcium and vitamin D, offer their patients bone-strengthening activities and consider medications to prevent future fractures.

Government:
The public health system and governmental agencies can promote awareness among consumers and clinicians, improve linkages between the various components of the health care system, help train health professionals to screen for and treat bone disease, encourage public and private sector collaboration, and continue to monitor the bone health of population groups and the nation.

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