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Broker Guide
Disease Management Expansion FAQ for Large Groups
Starting January 2007, we have enhanced the Coronary Artery Disease (CAD), asthma, and diabetes disease management programs provided to our fully insured clients with more than 300 eligible employees.  In addition, we are adding a new program for Chronic Obstructive Pulmonary Disease (COPD). 

These enhanced disease management programs make use of tools that will help patients more closely adhere to standards of care, as well as reach a greater volume of members. There will be no changes to the program for Congestive Heart Failure (CHF).
Please read the FAQ below for full details on the enhanced program. 
Frequently Asked Questions
Frequently Asked Questions
What change in disease management programs is Blue Shield implementing as of January 1, 2007?
We are pleased to announce beginning January 1, 2007, Blue Shield will provide enhanced disease management programs to all fully insured clients with more than 300 eligible employees. We will continue to offer our program for Congestive Heart Failure(CHF) and will offer enhanced programs for asthma, diabetes and Coronary Artery Disease (CAD), as well as a new program for Chronic Obstructive Pulmonary Disease (COPD).
Why did Blue Shield add a program for COPD?
We included the enhanced program for COPD in the January 1, 2007 offering to all large employer groups because this is a high-cost disease state for which the nurse-led interventions demonstrated significantly positive results for improved health outcomes and cost of health care savings.
Why are these disease management programs considered "enhanced?"
These programs make use of proprietary clinical and information technology tools to help patients more closely adhere to standards of care, as well as provide outreach to a greater volume of members. The enhanced programs are based on nationally-recognized best-practice treatment guidelines and are accredited by both National Committee on Quality Assurance (NCQA) and URAC.
Why did Blue Shield decide to offer these enhanced disease management programs to all large groups as of January 1, 2007?
Blue Shield made the decision to offer these enhanced programs in large part due to a pilot study that demonstrated a 3:1 Return on Investment for participating large group Blue Shield customers, as well as excellent member satisfaction and improved health outcomes. Program cost-effectiveness results are based on the California Public Employees’ Retirement System (CalPERS) experience in 2005 compared to 2004.
How was a 3:1 ROI determined for these enhanced disease management programs?
Savings were largely attributable to favorable outcomes in reduced utilization rates for ER visits, admissions, and bed days per 1,000. The enhanced disease management programs resulted in members reporting high satisfaction and increased health and presenteeism. This pattern of results is consistent with the existing research literature about disease management programs and was independently verified by Blue Shield Medical Informatics and Healthways, our best-in-class vendor partner for these programs.
Will members be notified of this disease management program expansion?
Yes. Blue Shield care managers have notified members currently enrolled in the internal disease management programs that a transition will occur and informed of any changes they may experience as a result of the enhanced program offering. There will be no changes to the program for Congestive Heart Failure (CHF).
Which Blue Shield members qualify for these enhanced disease management programs?
In general, members with the following conditions qualify for the enhanced disease management programs:

 
Diabetes: Reliable evidence in claims of a diagnosis of Diabetes Mellitus. Excludes gestational diabetes.

 
CAD: Reliable evidence in claims of a diagnosis of acute myocardial infarction (heart attack), angina pectoris (chronic chest pain), or other chronic ischemic heart disease or evidence of a cardiac procedure (coronary therectomy/angioplasty, coronary bypass). Excludes patients with heart failure (managed in the CHF program), renal failure, and heart transplants.

 
COPD: Reliable evidence in claims of a diagnosis of chronic obstructive pulmonary disease or related condition (e.g.; chronic bronchitis, emphysema, bronchiectasis, or other chronic airway obstruction). Excludes patients with Asthma, who are managed in the Asthma program.

 
Asthma: Reliable evidence in claims of a diagnosis of Asthma. Excludes patients with COPD, who are managed in the COPD program.
How will members be identified for enrollment in the programs?
Members will mainly be identified via claims and pharmacy data.  Please note that personal health information is held strictly confidential.
Who should I contact if I have further questions or want more information about Blue Shield's enhanced disease management programs?
If you have further questions or would like to receive more information or an in-person presentation on Blue Shield’s enhanced disease management programs, please contact your Blue Shield Account Manager.
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