Oxford Health Insurance information, tips and advice

Constant Communication

Provider communication is the first step toward helping members receive the most appropriate care. While primary care physicians are the usual first line of contact with patients, patients often receive care from other providers, such as ancillary or emergency care facilities, without notifying their primary care physicians. A discontinuity in care can lead to a mis- or undiagnosed chronic condition. While the patient may not communicate this information to his provider, it is communicated to the individual's health plan through claims data.

Health plans house a wealth of information that, if processed correctly, can be used to improve the care patients receive. To translate this data into a comprehensive plan that patients and providers can use to create treatment options and care plans, health plans must remain in constant communication and work collaboratively with providers.

Many providers are under great time restraints and have an overwhelming number of patients. They do not always have sufficient time to fully review each patient's files to monitor which screenings their patients have received. By electronically integrating claims, lab and pharmacy data, Oxford can provide this information to providers via a printout of patients who may have missed certain preventive screenings, including childhood immunizations, adolescent well-care visits and flu vaccinations.

Health plan members who have missed important screenings such as Pap smears, mammograms and diabetic retinal screenings also receive a preventive care reminder mailing. These reminders are part of a program called Active Partner[R]. In addition, members can sign up to receive electronic exam reminders for mammograms, Pap smears and colon cancer screenings in Spanish or English.

Creating tools to allow providers to access a patient's benefit information is the next step. By having access to each patient's benefit options, providers can tailor a program that incorporates the patient's needs, while taking into consideration which benefits are covered under the patient's plan.

The most efficient, cost-effective and timely way to provide information to a network as large as Oxford's, which consists of more than 50,000 providers, is electronically. To develop appropriate technology, Oxford held focus groups, conducted one-on-one usability tests, looked at the types of information that providers requested over the phone, and compiled general feedback received through the Web.

We concluded that providers wanted to be able to request materials, change general practice information, check the benefits of their patients, request precertifications and submit referrals online. Completing paper referrals is a burdensome administrative process, so we created a system by which providers can file referrals electronically. By the end of 2001, 100 percent of all referrals were received electronically through either the Web, interactive voice response system or electronic data interchange (EDI).

A study released by the American Medical Association in 2001 found that physician use of the Internet increased by 89 percent from the previous year. Oxford continues to see the number of its provider-driven transactions increase. In May 2002, claims received via EDI topped 70 percent of all claims submissions, while provider Web transactions surpassed the 100,000 mark, demonstrating a 120 percent increase over May of last year. Using electronic technologies to communicate with the provider community complements the more traditional ways, such as mailings and personal interactions, we utilize to reach providers.

Patient Empowerment

Although providers are the main force behind behavior modification among their patients, the patient is ultimately responsible for the level of wellness he or she achieves. Because patients must be willing and ready to make the necessary lifestyle changes to improve health and avoid further complications, they need to understand their conditions and treatment options available.

Typically, informed patients and families make better decisions about their diagnosis, condition, and treatments. Understanding the issues surrounding a specific condition or disease helps patients ask the right questions and take advantage of appropriate services. Patients who take an active roll in their health are more likely to be satisfied with their care, as well as with the clinical outcomes.

Healthcare consumers are savvier than ever, searching the Internet for information concerning health topics that directly address their needs. By discussing the information found on the Internet, patients can better interact with their providers concerning their condition and make more educated decisions on treatment plans. However, the Internet also houses a great deal of incorrect and outdated information. Physicians may find themselves quelling fears of patients who have self-diagnosed based on Internet information, and combating misconceptions about diagnoses and treatments.

Oxford has tried to address these issues by creating a website centered on the informational needs of its members. On our website are resources for members at every level of wellness, including a health encyclopedia; preventive care content; information on complementary and alternative medicine; pediatric wellness information; and health assessments such as a mini-checkup or body mass index calculator.

Empowering patients with chronic conditions such as asthma, diabetes or congestive heart failure requires a comprehensive care plan reinforced by personalized case management. Case management provides additional reinforcement and encourages patients to follow care plans created by their providers.

Inside Case Management

Our DM programs have helped members manage their health. In 2001, our Better Breathing[R] program helped 55,000 asthma suffers in the New York metro area control their condition and lower hospital admissions by 33 percent and emergency room visits by 21 percent among Oxford's asthma members. Our diabetes management program, Living with Diabetes[R], helped percent of the 47,000 diabetics enrolled in this program in 2001 receive their LDL-C, a test that determines bad cholesterol in the blood.

We have enjoyed a number of DM success stories, including a five-year-old diagnosed with asthma. Working with the girl's mother, our nurse case manager helped the family come to terms with the physician's diagnosis. Before the case manager got involved, the child was unable to go outside with her classmates during recess. The family feared that if she participated in any form of rigorous activity, she would have a severe asthmatic episode. The youngster began to feel left out and disconnected. Through case management, medication and an appropriate treatment plan, the child was able to better manage her condition and rejoin her classmates for recess.

By working collaboratively with providers and empowering members, Oxford helps its members receive the most appropriate care according to the clinical guidelines established for the member's condition. Over the coming year, we will further align electronic initiatives to follow the disease management programs; look into purchasing software that allows case managers to work with providers to create standardized care plans and manage more cases; create Web-based outlets that allow members to interact with the plan; and continue to look for tools that help tailor wellness initiatives to individual members.

For more information about Oxford Health Plans' Active Partner[R] program, .com/209ht-194

Richard Petrucci, ., is vice president of disease and quality management, Oxford Health Plans Inc., Trumbull, CT. Contact him at ssilk .