disease management

health resources

Answers to managing chronic conditions

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Humana Plans are offered by the Family of Insurance and Health Plan Companies including Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc.,

Humana Health Plans of Michigan, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. –

A Health Maintenance Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky,

Emphesys Insurance Company, or Humana Insurance of Puerto Rico, Inc. License # 00187-0009

For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Humana Insurance Company, Emphesys Insurance Company

Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance) for more information on the company providing your benefits.

Our health benefit plans have limitations and exclusions.

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Avoiding complicationsChronic diseases require a coordinated and multi-dimensional approach to care. Our goal is to help members by providing education and information so they work better with their doctor to manage their conditions and avoid complications.

Humana’s disease management programs promote:

• Preventing recurrence of symptoms

• Reducing hospitalizations and emergency room visits

• Prolonging periods of wellness, decreasing periods of illness

• Maximizing quality of life

• Reducing the need for future health services

• Improving health outcomes

• Reducing costs

*Agency for Healthcare Research and Quality http://www.ahrq.gov/news/ulp/chronic/ulpchron1.htm Accessed September 2006

Disease Management – guidance for managing chronic conditions

Chronic disease: the most common – and costly – health problemChronic conditions are the leading cause of death and disability in the U.S., affecting 45 percent of the population. Healthcare spending on chronic diseases accounts for 78 percent of all expenditures, and the number of people with these conditions is rapidly increasing.*

With this in mind, Humana offers disease management programs, addressing more than 20 conditions:

• Coronary artery disease

• Heart failure

• Diabetes

• Asthma

• Chronic kidney disease

• End-stage renal disease

• Cancer

• 13 less common conditions (including cystic fibrosis, Parkinson’s disease, and multiple sclerosis)

People with chronic conditions are the heaviest

users of medical care:*

• 96% of home health visits• 88% of prescription drugs

• 76% of inpatient stays• 72% of physician visits

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Meeting specific needs

A tailored fitContact with participants is tailored to each person’s needs, concerns, and readiness to change. Nurses strive to empower participants with education and tools that promote self-monitoring and prompt responses to early signs and symptoms.

As a support to the doctor-patient relationship and treatment plan, these voluntary programs include:

• Coaching, support, and service coordination through specially trained nurses who are available 24 hours a day via a toll-free telephone number

• Condition-specific Websites and newsletters that provide additional information and education

• Biometric devices that support the management of the condition, where appropriate

Improving health outcomesWorking with disease management nurses provides the individual guidance that helps lessen the day-to-day impact of chronic illnesses.

75% of chronic illnesses are related to

lifestyle behaviors, such as smoking, diet, and inactivity.*

*“ How Not to Be My Patient: A Physician’s Secrets for Staying Healthy and Surviving Any Diagnosis.” Dr. Edward Creagan, Mayo Clinic Oncologist.3 4

Healthier employees are happier employees

A health benefit – for employers tooDisease management programs not only help people with chronic illness improve their health; they also save money.

Disease management programs are recognized as an effective way to support employees in taking control of their health and making educated decisions about their care. And with healthier employees come additional benefits to employers:*

• Reduced medical costs

• Reduced administrative costs

• Increased productivity and attendance

• Increased employee satisfaction and retention

Humana’s disease management programs received ISO 9001:2000 certification, ensuring

employers and members receive efficient

and effective support.

Please see the following pages for more information about each program.

*Actual Humana experience5 6

Registered nurses are available to help members get the most of Humana’s clinical guidance and support services. Members can call HumanaFirst®

and select Health Planning and Support:

1-800-622-9529

Heart failure (HF) is one of the nation’s most

costly diseases, both in terms of quality of life as well as dollar expense. This is a serious condition in which the heart’s pumping action is compromised. Heart failure affects nearly five million Americans, with 550,000 new cases diagnosed each year.

The cost of hospitalization for

heart failure is two times that for all

forms of cancer.*

Heart failure:a major burden on U.S. health

The HF program is targeted to those with moderate to severe heart failure. The program is NCQA accredited and delivered primarily through critical care nurses who assist participants through a combination of intervention, monitoring, and education. The program includes:

• Screening to identify candidates for the program

• Linking eligible members with a cardiac-trained registered nurse

• Telephonic outreach by a nurse, who assesses needs and provides education and ongoing support

• Reinforcing the importance of adherence to the physician’s plan of care

Improving outcomes

The HF program is showing excellent outcomes. Collaboration among the member, the physicians, and the nurses leads to improved care for those with heart failure, enabling an increased quality of life. Data show the following trends:

• The HF program demonstrated an Emergency Room (ER) visit rate of 40/1000 participants per month, compared with a national benchmark of 84/1000

(52% below national benchmark)

• Hospital admission rates were 84/1000 participants per month, compared with a national benchmark of 87.2/1000

• 76% of program participants report vasodilator compliance, compared with a national benchmark of 63%

(21% above national benchmark)

• 94% member satisfaction rate

The HF program demonstrated an ER

visit rate 52% below national benchmark.

*The Am J Cardiol. 83 (2A), Jan 21, 19997 8

Rare diseases:supporting those with less common conditions

Humana’s program for rare diseases is designed

to address the needs of less common conditions.

This program helps with the management of the following 13 chronic, degenerative diseases:

• Amyotrophic Lateral Sclerosis (ALS, or Lou Gehrig’s Disease)

• Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)

• Cystic Fibrosis• Dermatomyositis• Hemophilia• Lupus (Systemic Lupus Erythematosus) • Multiple Sclerosis (MS)• Myasthenia Gravis• Parkinson’s Disease• Polymyositis• Rheumatoid Arthritis• Scleroderma• Sickle Cell Disease

Direct medical costs for cystic fibrosis are in excess of

$40,000 per patient, per year.*

Our rare diseases program implements a team approach to address the individual’s medical, educational, and psychological needs. The following are included in the program:

• Screening to identify candidates for the program

• Disease-specific online tools and resources

• Service coordination and education via telephone contact

• Continued communication with participants and their families, including anticipation and resolution of

disease-specific issues as well as general support

• 24-hour, toll-free access to specially trained nurses

• Quarterly outcome reports

Improving outcomes

Through specific programs for each disease, participants receive information tailored to their individual situation, helping contribute to positive outcomes. Such outcomes include:

• 99% of enrolled lupus participants are able to identify the warning signs of infection, a serious complication of their disease

• 93% of enrolled cystic fibrosis participants are able to perform daily airway clearance, which lowers their risk for inpatient admissions

• 100% of hemophilia participants are aware of early bleeding symptom management, a significant complication of their disease

*http://www.lungusa.org/site/apps/s/content.asp?c=dvLUK9O0E&b=34706&ct=378046 Accessed September 2006

More than 8,700 members are currently enrolled in Humana’s rare diseases program.

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End-stage renal disease (ESRD):a chronic, life-threatening illness

End-stage renal disease (ESRD) is a chronic,

life-threatening condition that usually develops over a period of years. An end result of chronic kidney disease, ESRD occurs when the kidneys are no longer able to function at a level that is necessary for day-to-day life and dialysis is required.

2003 end-stage renal disease costs:

$27.3 billion in public and private spending

in the U.S.*

The end-stage renal disease program provides case management designed to address quality-of-life issues for those with this life-threatening condition. ESRD staff work closely with participants, local nephrologists, and dialysis centers to coordinate services and monitor medical management. Program components include:

• Assessment and care planning with an interdisciplinary team

• Education about kidney disease; when to report signs and symptoms; managing diabetes, high blood pressure, and heart disease;

and medication compliance

• Case management and coordination of services designed by a panel of nationally recognized nephrologists

• Application of protocols and guidelines in efforts to address comorbid conditions

Improving outcomesPositive clinical outcomes of this program include:

• 97% of program participants have hemodialysis adequacy, compared with a national benchmark of 91% (7% above national average)

• 85% of program participants have acceptable hemoglobin levels, compared with a national benchmark of 80% (6% above national average)

• Hospital bed days are reduced to 2.3 for program participants, compared with a national average of 3.6

*United States Renal Data System, 2003, NIDDK; http://kidney.niddk.nih.gov/kudiseases/pubs/kustats Accessed September 2006

†1st quarter 2006

Participants in Humana’s ESRD

program are 36% below national

average in hospital bed days.†

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Chronic kidney disease (CKD):a growing health problem

Total yearly healthcare costs for CKD patients

with comorbidities average $6,245.*

Chronic kidney disease is the slow, progressive

loss of kidney function. One in nine adults in the U.S. has CKD, and another 20 million more are in a high risk group. These include those with diabetes, hypertension, or a family history of kidney disease. Early detection and treatment can help prevent or delay the progression to kidney failure and end-stage renal disease.

The CKD program uses a range of management approaches, from telephone contact with members to extensive and regular face-to-face contact, depending on member needs. Health Service Coordinators (HSC) – field-based, experienced nephrology nurses – work with program participants and providers to accomplish the following: • A comprehensive, personal assessment of the participant’s current needs

• A care plan through collaboration of the HSC and the primary care physician

• A nephrology referral, if necessary

• A collection of clinical indicators

• Quarterly reports of outcomes

Providing coordination and

member education

The CKD program assists in obtaining the most appropriate health care and support services, while achieving the maximum cost-effective use of resources. The program focuses on high-quality care and member education, including:

• Education on the progression of renal disease

• Education on treatment options

• Early referral to nephrologists

• Appropriate placement of access in an outpatient setting

• Education on the prevention and management of associated comorbid complications

• Psychosocial support as the progression of the disease occurs

*J Am Soc Nephrol. 2004;15:1363-1364.

The goal of the CKD program is

to prevent or delay the progression of CKD

to life-threatening ESRD.

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Coronary artery disease:a high risk and a growing concern

Coronary artery disease (CAD) is the most

common type of heart disease. About 13 million people in the U.S. have CAD, and it is the leading cause of death in the U.S. for both men and women. Each year, more than half a million Americans die from CAD.

Cardiovascular disease accounts for an estimated

$209.3 billion in direct costs.*

The goal of the coronary artery disease program is to help participants adhere to their physicians’ prescription and treatment plan, monitor their health status for complications, and decrease their cardiovascular risks. Designed to complement the prescribed treatment plan of the physician, this nine-month program includes:

• Proactive identification of candidates and invitation to join the voluntary program

• Availability of specialized cardiac nurses via a toll-free number, 24 hours a day, seven days a week, to discuss issues and answer questions

• Ongoing guidance and education focused on clinical and behavioral issues, such as smoking, high blood pressure, elevated lipid

levels, lack of exercise, and the importance of

taking medications

• Close contact with the participating physician to assist with the plan of care and ongoing treatment

Improving outcomes

The CAD program provides intensive care and support to those members at risk of having a further cardiac event. The most recent outcomes reveal:

• 83% of participants are receiving appropriate beta blocker therapy compared with the industry standard of 62% (34% above industry standard)

• ER visit rates are 26/1000 participants per month compared to the current commercial industry rate of 52/1000 (50% below industry average)

• 86% of program participants are on antilipemics as compared to a 2003 Annals of Internal Medicine study of 53%

*http://www.bloomberg.com/apps/news?pid=10000082&sid =a4J.ER8r4CrM&refer=canada Accessed September 2006† 1st quarter 2006

Humana’s CAD program averages

50% below industry average

for ER visit rates.†

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Oncology program:for members in active cancer treatment

The National Institutes of Health estimated the total

annual health expenditures for cancer

to be $74 billion.

Cancer patients face many decisions

after the initial diagnosis. It’s often hard to know which treatments and options to pursue. Knowing what to expect during and after treatment, both physically and emotionally, can be a great help. Cancer patients and their caregivers need support during a difficult time.

Fear, anxiety, and confusion are natural reactions when someone is diagnosed with cancer. Humana’s cancer management program helps by offering support and educational services for adults with biopsy-proven cancer who:

• Have begun or are planning to undergo surgery, chemotherapy, radiation therapy, or biologic therapy

• Have a history of cancer that has recurred and needs treatment

• Have declined further therapy but require supportive management (before accepting hospice)

Providing support at a time

when it’s needed most

Humana’s oncology care managers have an average of 10 years of professional experience in understanding cancer, its symptoms, its side effects, and treatments. The program includes:

• Educating the member and family about the disease and its medical management

• Reinforcing the importance of the treating physician’s prescribed plan of care

• Addressing side effects of therapy to increase the member’s comfort

• Attempting to avoid hospitalizations

• Monitoring compliance with medications

• Helping transition through active treatment to recovery

• Supporting informed end-of-life decisions, when appropriate

*http://www.cancer.org/docroot/MIT/content/MIT_3_2x_Costs_of_Cancer.asp Accessed September 2006

Humana’s oncology managers average

10 years of professional

experience.

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Diabetes:reaching epidemic proportions

According to the Center for Disease Control (CDC),

more than 20.8 million people in the U.S.

have diabetes. The disease is associated with higher rates of lost work time, disability, and premature death. The resulting loss to the U.S. economy is estimated at $40 billion per year.*

To address increasing expenditures related to diabetes and its complications, Humana has implemented a high-acuity program for both type 1 and type 2 diabetics over the age of 18. The program is delivered by registered nurses who receive additional training in diabetes disease management. The program includes:

• Ongoing education about disease management and monitoring in the areas of diet, exercise, and lifestyle

• Availability of registered nurses via a toll-free number, 24 hours a day, seven days a week, to answer

questions from the participant and family members

• Management of additional conditions, which often include heart disease, kidney disease, eye disease, and stroke

• Biometric devices (scale, blood glucose monitor) for eligible participants

Improving outcomes

Positive clinical outcomes for the program include:

• 79% of program participants for the period ending 3/2006 report having an annual eye exam as compared to a 2002 Annals of Internal Medicine study rate of 63%.

• 88% of program participants for the period ending 3/2006 report having an annual foot exam as compared to a 2002 Annals of Internal Medicine study

rate of 55%.

*http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf Accessed September 2006

† http://care.diabetesjournals.org/cgi/content/full/26/3/917 Accessed September 2006

The economic costs of diabetes are enormous: $132 billion

in 2002.†

9.6% of those aged 20 years or older

have diabetes.*

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Asthma:a common and costly disease

Direct costs of asthma total more than $9.4 billion

every year.*

More Americans than ever before are suffering

from asthma. It is one of this country’s most common and costly diseases. Every day, 40,000 people miss school or work due to asthma, and more than one-fourth of all emergency room visits in the U.S. are asthma-related. According to the American Lung Association, asthma is the third leading cause of hospitalizations among children under the age of 15.

The Humana asthma disease management program offers education to members so they can understand their disease better and take a more active role in controlling it. A major goal of the program is that members will adhere to the treatment plan prescribed by their physician. In support of that goal, this 12-month program provides:

• Educational materials and monitoring in the areas of proper asthma management and control

• Where available, home respiratory therapist visits; otherwise, telephonic assessment by a respiratory therapist

• Follow-up by telephone with a respiratory therapist

• Environmental assessment to identify asthma triggers

• Durable medical equipment and instruction, including a peak flow meter and spacer

• Communication with healthcare provider to develop an asthma action plan if the member does not have one

• Smoking cessation education

Improving outcomes

Goals of the program are to improve outcomes by:

• Helping members increase self-monitoring skills

• Promoting compliance with controller medications

• Reducing frequency of hospitalization

• Improving quality of life

*http://www.aaaai.org/patients/advocate/2004/fall/costs.stm Accessed September 2006

Direct costs for asthma-related

hospital services exceed $4 billion annually.*

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