New Paradigm for DM

At the time, Eric Book had no idea that his experiences managing a cabin of kids during medical school summers would help prepare him for developing effective case and disease management programs for Blue Shield of California.

"At a children's camp, you are trying to manage the enjoyment the children get for a period of time when they are away from school and away from their families. Is that much different from managing the quality of life in the healthcare environment?" Book asks. "Who knows? Maybe it prepared me, but on the other hand, maybe I did it because that's the way I'm hardwired."

Either way, he went on later in life to develop unique voluntary case management programs to improve care and reduce medical costs. Making use of patient data — from physician coding to individuals filling prescriptions to nurses inputing exam information — and of technology through ParadigmHealth's algorithms, Book developed a way of providing better care for his members.

The Early Days

On one level, Book appears to have been interested in disease management programs like the one he developed for quite some time. In the late 1980s and early 1990s, Book says he became attracted to an early movement in healthcare to migrate industrial methods for continuous quality improvement into the healthcare environment, which appears to have had great impact in laying the groundwork.

Book was familiar with the methodologies and teachings on process-improvement and total quality management of W. Edwards Deming and Joseph Juran, and of the data-driven Six Sigma approach to achieving perfection. Applying these industrial approaches and methodologies to healthcare, he worked to reduce medical error rates and improve quality and safety for patients.

"The consensus was that people who are chronically ill, basically need our attention," he says. "There are certain diseases which affect a large number of people — at least 5 percent of the population has diabetes, 5 percent of the population or so has asthma, and heart disease is still the leading cause of death in this country," he says. "So, it made sense to identify individuals with chronic diseases and help them manage the burden of illness. As we learned more about the cost drivers of healthcare, we became aware that it's not just people with chronic disease, it's also individuals with acute complex diseases."

After working at a camp in Ontario and graduating from the University of Toronto, Book went on to Sunnyvale, Calif.'s Sunnyvale Medical Clinic (now Camino Medical Group), first as a family physician, and later as a medical director. He particularly enjoyed the long-term relationships he developed with individuals and families as a family physician, helping people manage their health, preventing disease, "and if they became ill, helping them reduce their burden of illness."

His move from practicing medicine to management was about simple time management. As his clinical time gradually decreased and his management time increased, it reached the point where he was essentially in management fulltime. "It kind of snuck up on me, so to speak," he says, but what didn't was his disease management innovation.

After 17 years at Sunnyvale and five years as chief medical officer at Des Moines-headquartered Wellmark, Inc., (Blue Cross and Blue Shield for Iowa and South Dakota), Book joined San Francisco-headquartered Blue Shield of California in 2002.

Big numbers at Blue Shield

"The big difference between being a family physician and being a chief medical officer of a plan is that instead of being responsible for the health and well being and managing the illness for a relatively small number of people one at a time, my team and I are managing care for 3 million Californians," he says.

What this meant, Book discovered, was that he needed to come up with some sort of way to manage the care of a massive number of people, particularly those who needed it most. "We brainstormed four years ago and said, 'How can we adequately capture the people who need our attention the most, and what type of programs do we need?’”

Book's disease management program development began with the understanding that 1 percent of Blue Shield's members were the sickest, consuming between 30 and 35 percent of the healthcare dollars.

ParadigmHealth uses Electronic Care Management Qualification Logic (ECMQL) and Program Triage Logic (PTL) to identify cases for disease management services, while classifying members who will benefit from focused care-management services.

• The system triages acute and clinically complex patients to be managed, while segmenting plan members who will benefit from disease-management services into discrete groups.

• The integrated care management system fills the gaps that exist within a health plan's care-management modules with a filter calibrated to the degree of specificity selected by the plan.

"So one way of looking at this is the application of Sutton's Law," Book says, referring to the principle of going straight to the most likely diagnosis. (When asked why he robbed banks, Willy Sutton legendarily said, "Because that's where the money is.") "We're going where the action is," adds Book.

Book figured if the sickest 1 percent was using that many medical resources, it was "a golden opportunity to try and reduce the burden of illness." Book says he knew that these were the people who had the poorest quality of life, and that by improving their quality of life, he might also reduce their utilization of medical and pharmaceutical resources which would help to control their premium.

In order to "facilitate that individuals receive optimal care at the optimal time in the optimal place," as Book says, he called in a vendor. "We like to say, 'The right care at the right time in the right place.’” To decipher whom to watch the closest, Book decided it would be best to mine through claims data and identify the members who needed the most attentive care.

After that, Book wanted to stratify these chronically ill members in four levels of severity. In order to execute on such a massive identification and stratification process, Blue Shield partnered with Upper Saddle River, N.J.-based ParadigmHealth, that set up a data pipeline using a series of algorithms for five chronic diseases — diabetes, asthma, heart disease, congestive heart failure and chronic pulmonary disease.

With members identified, Blue Shield nurses were able to take better aim at the sickest patients to see that they were following physician instructions, getting necessary preventive care, complying with their medicines and getting the annual or periodic exams necessary to manage their conditions.

In addition to individuals with chronic conditions, Blue Shield and ParadigmHealth developed a complex case management program designed to track those who suddenly develop an acute or complex illness that requires case management. "A lot of those individuals, between 70 and 80 percent, find out they have a terminal illness or have very complex problems that if not treated aggressively could result in a terminal condition, but are certainly resulting in a decreased quality of life," Book says. Also designed for individuals with complex trauma and including those with severe burns, as well as infants who have gone into newborn intensive care programs, participants spend four to five months in the program on average.

As for the future, Book has his eyes on expanding the complex case management program currently in use. He is piloting an expansion for what he calls the next level down of severity for people with less common diagnoses such as later-stage multiple sclerosis, rheumatoid arthritis, lupus and sickle cell anemia.