Eighty percent of responding health plans reported that they identified members with elevated CMR. The methods used most frequently included referral from case or care management (89%), HRA data (86%), claims data (82%), and pharmacy use data (79%). However, medical officers of more than 70% of the plans also reported that they use provider referral to identify members with elevated CMR. Data from enrollment forms are rarely used.
More than 80% of medical officers of health plans reported that they address CMR among their enrollees as part of both a wellness/prevention domain and as part of a chronic care management domain. Nearly two-thirds of the plans reported that they also address CMR as part of a management or treatment domain.
Nearly all plans reported that they offer wellness, health promotion, or prevention programs to members for tobacco use, obesity/overweight, nutrition, and physical activity (). Although fewer health plans offer these services to employers, the rank order of the frequency with which the services are offered is approximately the same. The pattern for programs offered to clinicians was different from the pattern offered to members. Programs most frequently offered to clinicians address cholesterol control, hypertension, tobacco use, and high triglycerides.
Percentage of health insurance plans with wellness, health promotion, or prevention programs/activities for members, employers, clinicians, and communities, by program type, 35 members of America's Health Insurance Plans, United States, January 2008.
Nearly all of the plans address nutrition, cholesterol control, hypertension, tobacco use, physical activity, and obesity/overweight as part of their existing diabetes and cardiovascular disease chronic care programs. Approximately half of the plans address CMR as part of obesity programs. The proportions were lower for cancer, asthma, and chronic obstructive lung disease programs.
Medical officers of responding health plans reported using multiple strategies to assist enrollees in managing elevated CMR (). All health plans use feedback from HRA, and nearly all plans provide Web-based tools and resources, patient educational materials/brochures, and referrals to case management/chronic care programs that their enrollees can access. Strategies most frequently named as among the 3 most effective in helping enrollees manage CMR were health coaching, feedback from HRA, referral to case management, and incentives. Although they were not perceived to be the most effective strategies, health plans also frequently reported using tobacco use cessation programs, work site services (eg, health education classes, cafeteria assessments, weight management programs), and nutrition counseling.
Figure 2 Percentage of health insurance plans that use strategies to help enrollees manage cardiometabolic risk and percentage of health insurance plans that rank the strategy as among the 3 most effective, by strategy, 35 members of America's Health Insurance (more ...)
The 5 strategies that health plans reported using most frequently to assist clinicians to evaluate and manage CMR were evidence-based guidelines, feedback to providers (eg, physician reports, provider profiling), care coordination, pay for performance, and pharmacy programs (). Most frequently reported among the 3 most effective strategies were the use of evidence-based guidelines, feedback to providers, and pay for performance programs. Although they were not perceived as the most effective strategies, health plans also frequently reported using the following strategies/interventions to assist clinicians to evaluate and manage CMR: consultation/referral to tobacco use cessation services, patient educational materials at provider offices, and information technology tools to providers.
Figure 3 Percentage of health insurance plans that use strategies to assist clinicians evaluate and manage enrollees' cardiometabolic risk and percentage of health insurance plans that rank the strategy among the 3 most effective, by strategy, 35 members of America's (more ...)
Use of guidelines
More than 80% of medical officers of health plans cited the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III), USPSTF recommendation, and the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure as guidelines that they use to identify, manage, or treat enrollees with elevated CMR. Approximately half of the health plan medical officers also reported using other guidelines. Other guidelines that were used included those developed by the National Institutes of Health, United States Public Health Service, American Heart Association, and American Diabetes Association, as well as guidelines developed by regional and local groups. Health plan medical officers reported infrequently using international, European, and subspecialty guidelines to identify, manage, or treat enrollees with CMR.
Risk assessment tools
Approximately half of the health plans advocated a risk assessment tool to members or clinicians. When a risk calculator was advocated, it was approximately equally likely to be the NCEP tool or the Framingham risk calculator. Risk calculators that included CMR factors, for example Diabetes PHD (Personal Health Decisions), Reynolds Risk Score, and the PROCAM (Prospective Cardiovascular Münster) score, were recommended infrequently or not at all to members, clinicians, or employers. Approximately one-third of health plans recommended 1 or more of the risk assessment tools to address CMR.
Barriers to implementation
Medical officers of health plans most frequently reported shortage of resources, lack of reporting systems, and lack of enrollee-level data as barriers that they face in addressing CMR (). These same 3 barriers were reported to be among the top 3 barriers to implementation. Although they were not identified as being the most important barriers, lack of patient adherence to medication regimen, lack of physician time to counsel and educate patients, lack of enrollee interest, and poor or unknown return on investment were frequently cited by health plans.
Figure 4 Percentage of health insurance plans that face barriers to addressing cardiometabolic risk and percentage of health insurance plans that rank the barrier among the top 3, by barrier, 35 members of America's Health Insurance Plans, United States, January (more ...)
Plans for the future
Regarding plans to address CMR, medical officers of 57% of health plans reported that they are planning to expand their activities in the next 2 years, 29% reported being unsure of their plans, and the remaining 14% indicated that they have no plans to expand activities in this area.