ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Sunday, June 9, 1996 TAG: 9606100018
SECTION: BUSINESS PAGE: BUSINESS EDITION: METRO
SOURCE: SANDRA BROWN KELLY STAFF WRITER
"Hi, it's Cheryl from Universal RX. I was calling to check on you this month to see if you need your diabetic supplies. How have your blood sugars been running?"
Cheryl Tyler, seated at a desk in a building near Roanoke Regional Airport, is calling her customers. On the other end of the line are diabetics. They are employees - or dependents of employees - of Western Virginia companies that have bought Universal's disease management service. It is offered through the Blue Ridge Regional Health Care Coalition.
The companies include Pulaski Furniture Co. in the New River Valley, which insures Bonnie Long of Pulaski. Long's husband, Billy Joe Long, works at Pulaski's Dublin plant.
Bonnie Long, 48, was diagnosed with diabetes the second week in April. Her doctors prescribed insulin pills and told her to test her urine twice a day to make certain the medication was keeping the sugar level under control. It was three times her normal level when she was diagnosed.
The specially treated paper strips Long needed for the tests cost $18 for 25. Her husband was the only family member working, and he was on a 32-hour week, so she skimped on the testing to save money.
"I did it twice a week in the beginning," she said.
But last month, Long's husband brought home a notice that Pulaski had bought Universal's prescription drug service as an employee benefit, which includes the special program for diabetics.
Long didn't even wait for Tyler's call.
"I called them," she said.
She found out she could get 100 test strips for about the same she had paid for 25. Also, she would get regular calls from Universal's staff, who would help her with reorders and information on her illness.
"That was great because this is all new to me," Long said.
Pulaski Furniture expects Universal's program to save the company and its employees money on health care and also improve the lifestyle for workers and their family members who have diabetes.
Universal RX is a division of Universal Self Care Co., which developed the country's first diabetes supply and disease management program in 1994 for Black & Decker Corp. in Towson, Md.
It can ship supplies and medications needed by diabetics and help them control their illnesses. The division's president, Ed Bucholz, describes Universal RX as a one-stop shopping source for a health care group's information, disease management and prescription benefit needs.
By disease management he means simply trying to get an individual to do all he or she can to stay healthy. It has all the accouterments of other well-meaning efforts, such as charity fund raising and church outreach. A friendly manner. Concern for the person called; maybe even a question about a child's health or a pet's condition. Then, the reason for the call.
If a customer's test results are out of kilter, Universal's Tyler will ask about eating habits.
"We just remind them they need to be eating correctly and that we have literature to send out," Tyler said.
She also keeps a computer log of her customers' general habits. She might make a note if one of them is planning a vacation so she can remember to ask about it during a call later. Or, Tyler might offer to send the customer a video about "Traveling With Insulin."
Tyler's job is to raise the health consciousness of the people she phones and talks with for 10 or 15 minutes a month. If they stay healthy, it will save money for their employers, who are her company's customers.
"We try to be gentle nuzzlers," she said.
Health care data shows that 10 percent of people account for 70 percent of the health care spending and that big chunks are consumed by people with chronic conditions, such as diabetes.
If a diabetic lets sugar or insulin levels become unbalanced or fails to eat correctly, he or she runs the risk of needing hospital care. Uncontrolled diabetes leads to heart disease and circulation problems that can result in amputation of a limb.
Why would Pulaski Furniture want to develop a diabetes management plan?
Based on its employment numbers, Pulaski could have as many as 80 diabetics in its group insurance coverage group. If their illness isn't kept in check, those 80 people could use 16 percent of the company's annual health care budget with hospitalizations and other illnesses related to their disease, said Jan Sessor, national accounts manager for Universal RX.
Sessor estimates that the employees and dependents of coalition members who have bought Universal's prescription benefits might include as many as 300 diabetics.
Universal will next add an asthma management service and follow that with special programs for people suffering from hypertension and depression. The information that Universal collects from its prescription drug cards is expected to provide the data to direct program development, Sessor said. |n n| Universal is the second health care "monitoring" program Pulaski Furniture has purchased through the regional health coalition. Four years ago it bought the services of Corview Inc., a Minneapolis medical management company.
Corview has saved Pulaski "several hundred thousand dollars," said Pete Crawford, the furniture manufacturer's vice president for administration.
Pulaski Furniture funds its own health insurance, as do many of the 45 coalition members in the Roanoke and New River valleys. What the coalition has tried to do is provide a selection of insurance services for its members to shop to their 30,000 workers, Crawford said.
While Universal tries to help people avoid health problems, Corview Inc. attempts to make certain that when people do become ill or get injured, they get the lowest-cost effective treatment. The company is concerned that medical bills are not inflated and that workers don't get treatments they don't need.
Corview contends that enough money is spent on health care to provide "excellent benefits if companies eliminate inappropriate charges and unnecessary procedures and make sure that medical services are done efficiently," said Fred Oss, director of marketing.
For example:
Changing the 11442 code for a benign - or noncancerous - lesion to the 11642 code for a cancerous lesion can increase reimbursement from $100 to about $750, he said. Scheduling outpatient surgery too late for the person to recover by evening can result in a $500 overnight hospital stay.
Corview touts its exclusive use of practicing physicians to review cases as setting it apart from other review companies that use less-skilled reviewers. The doctors all must be in active practice, which makes them able to judge what treatments or surgeries proposed aren't really needed, Corview contends.
Some of the "not-medically-necessary" procedures that Corview identified for the Blue Ridge coalition members were documented in the contest entry that won the health group an award last month. from the national Managed Health Care Congress in Washington, D.C. It cited the Corview program as saving coalition members about $1.5 million last year.
In 1993, Corview found that 60 percent of the requests for tonsillectomies on people covered by the 10 coalition members that Corview serves were made before more conservative treatment was tried, Oss said. Corview also identified an excessive amount of spine surgery in the coalition's coverage group. Because of that, in 1993 and 1994, the rate of "unnecessary" requests for back surgery went from 15 per 10,000 to about five per 10,000 employees, he said.
More recently, Corview physicians discovered that a psychiatric counselor in the Martinsville area was getting what amounted to a kickback for referring patients for hospitalization, Oss said.
The hospital was paying the doctor what he would have gotten for outpatient services in exchange for getting higher in-patient insurance payments.
Corview caught up with the problem because all of the patients were from one company and all of the referrals from one counselor, Oss said.
Corview called up the parties involved and told them to quit.
Procedures now under special scrutiny include hysterectomies and colonoscopies, during which the interior of the colon is viewed through a flexible scope.
Scope procedures are the No. 1 "overuse" issue for the Blue Ridge group, Oss said. A physician's bill alone for a scope procedure can run up to $2,000, he said.
The coalition first offered a managed care program in 1984. In March it added a special insurance program for small companies - including those with as few as two employees. It's called the Virginia Health Protection Plan and is a joint effort with Nationwide Insurance Enterprise.
All of the coalition's programs now are offered statewide through a new health group, Commonwealth Coalitions on Health. It was founded in February by the Blue Ridge group and the Richmond Area Business Group on Health Inc.
Crawford said Pulaski Furniture joined the Blue Ridge coalition four years ago to look for ways to stop rising health care costs for the company and its 2,300 employees. He is the current president of the coalition.
"We have not raised employees' premiums for going on four years now, and we're still providing all the medical services," Crawford said.
LENGTH: Long : 163 lines ILLUSTRATION: PHOTO: Wayne Deel. 1. Cheryl Tyler makes periodic calls toby CNBUniversal RX customers who are diabetics. The purpose of the calls
is to raise the health consciousness of the diabetics so they stay
healthy. "We try to be gentle nuzzlers," she said. 2. Jan Sessor,
national accounts manager, believes as many as 300 diabetics may be
receiving Universal's prescription benefits. color. Graphic: Charts
by staff. 1. Rate of unnecessary services. 2. Savingws breakdown.
color.