The State of Preventive Health A report from Blue Cross and Blue Shield of North Carolina

Transcription

1 The State of Preventive Health A report from Blue Cross and Blue Shield of North Carolina November 2003

2 Preface Dear Friends, It s common knowledge that when it comes to your health, a little prevention goes a long way. Yet not enough North Carolinians are engaging in good preventive health behaviors and as a result, our state continues to suffer from high rates of chronic and costly disease. To better understand preventive health patterns among its membership, Blue Cross and Blue Shield of North Carolina undertook an extensive analysis of claims data from The analysis shows why our members are seeking medical care, how much it s costing and where gaps exist in regular health screenings and preventive care. We also surveyed a portion of our members to gain greater insight into preventive health beliefs, attitudes and practices. This report is based on data results from nearly 700,000 members of our health plans. The size of the sample and depth of the study provide a comprehensive look at preventive health practices across North Carolina s insured population. While preventive health examinations and screenings are among the most frequent reasons our members go to the doctor, the report shows that a relatively low proportion of members especially men received a preventive health exam in At the same time, the cost of treating conditions that are at least partly preventable rose dramatically. The State of Preventive Health report recommends specific actions for our members, health care providers and North Carolinians in general. It also highlights work already under way at Blue Cross and Blue Shield of North Carolina to encourage good preventive health. We hope this report will generate discussion that leads to sound health care policy and preventive health efforts throughout the state. We plan to conduct regular analyses and surveys and issue future reports so that progress can be measured and further needs identified. Armed with the right knowledge of preventive health behaviors and needs, together we can help make North Carolina a leading state in preventive health. Best Regards, Bob Greczyn President and Chief Executive Officer Blue Cross and Blue Shield of North Carolina

3 Methodology Blue Cross and Blue Shield of North Carolina (BCBSNC) conducted a comprehensive assessment of its member population in the spring of 2003 to guide the company s health care quality improvement efforts. The assessment forms the basis of much of the data included in The State of Preventive Health report. BCBSNC analyzed claims and utilization data from 2002, based on standard diagnosis codes submitted by health care providers under the International Classification of Diseases, 9th revision (commonly known as ICD-9). The analysis also included demographic data such as age and gender. The analysis centered on the company s group plan membership in PPO, HMO and POS products. Both fully insured plans and self-insured plans (those in which the employer group assumes all insurance risk and pays BCBSNC a fee to administer the plan) were included in the data. Indemnity plan membership, individual plan membership, state employee membership and members of other Blue Cross and Blue Shield Plans who were served by BCBSNC were excluded. In total, there were 691,492 members whose data were included in the analysis. This figure approximates to slightly more than 8 percent of the state s population. Additionally, The State of Preventive Health report includes survey information compiled by the company in A comprehensive survey of members was taken at that time to assess preventive health behaviors and attitudes. The survey focused on members of the company s HMO and POS plans. A total of 6,535 surveys were sent to members, and the number of responses was 2,297. Where noted, we have included data from other sources to supplement this report. This report was prepared under the direction of the Health Care Services division of Blue Cross and Blue Shield of North Carolina, led by Dr. Robert T. Harris, senior vice president and chief medical officer. Additional copies of the report may be obtained from BCBSNC Corporate Communications at Questions about the data, conclusions and recommendations in the report should be directed to: Dr. Don Bradley, BCBSNC senior medical director for Quality Improvement, at or don.bradley@bcbsnc.com Cindy Brenneman, RN, director of Quality Management, at or cindy.brenneman@bcbsnc.com The State of Preventive Health 1

4 Regular health examinations and screenings are a crucial part of the total prevention picture because they provide physicians with opportunities to detect chronic diseases and potentially serious conditions in the early stages. 4 September 2003

5 Section 1: Health Examinations & Screenings Regular health examinations and screenings are a crucial part of the total prevention picture because they provide physicians with opportunities to detect chronic diseases and potentially serious conditions in the early stages. Equally important, a preventive health exam gives the doctor a chance to counsel the patient on healthy lifestyle choices such as proper nutrition and exercise. In 2002, 12.7 percent of members enrolled in PPO, HMO and POS plans from Blue Cross and Blue Shield of North Carolina received a routine medical exam. Women were slightly more likely than men to have received such an exam in percent of women in the study population, compared with 11.6 percent of men. Preventive Health Screenings by Gender Number of Visits 250, , , , ,808 Cervical Cancer Screening Breast Cancer Screening Gynecological Exam Routine Medical Exam 50,000 34,551 Female Gender Male Taking into account all major types of medical exams and health screenings, women were more than six times as likely to have received an exam or screening during the year. Women receive many additional preventive health services through OB/GYN physicians and also seek health screenings at a far greater rate than men. The State of Preventive Health 3

6 The 10 Most Common Medical Claims in 2002, ranked by number of members RANK PRIMARY DIAGNOSIS DESCRIPTION MEMBERS CLAIMS % TOTAL MEMBERS 1 Special Examinations 118, , % 2 Cancer Screening 89, , % 3 General Medical Exam 87, , % 4 Child Health Supervision 71, , % 5 General Symptoms 65, , % 6 Eyesight Problems 59,706 84, % 7 Respiratory System/Other Chest Symptoms 59, , % 8 High Blood Pressure (Essential Hypertension) 58, , % 9 Acute Upper Respiratory Infection Multiple Sites 58,145 98, % 10 Acute Sinusitis 57,466 97, % More BCBSNC members received special examinations than any other type of medical care during Special examinations are exams other than general medical exams or cancer screenings, and they include gynecological exams, eye exams and laboratory exams. This finding is encouraging in that special exams are a type of preventive care. However, the overwhelming majority (89.1 percent) of special exams were gynecological exams. In fact, three in 10 female members underwent a gynecological exam in Few men received exams in the special examinations category. Other reasons for special exams included eye exams (4.1 percent), unconfirmed pregnancy tests (3.3 percent) and laboratory exams (2.9 percent). The likelihood of women receiving a gynecological exam varied by age. Women in prime childbearing years were the most likely, at almost 40 percent. The rate slipped slightly among women ages 45 to 54, to 37.5 percent, and again among women ages 55 to 64, at 30.5 percent. As with special exams, women were considerably more likely to have received a cancer screening. The most frequent cancer screenings were for breast cancer (mammograms), followed by cervical cancer (Pap smears). 4 November 2003

7 Among adults, the most likely age group to seek preventive care is 55 to 64, but even in this group just slightly more than one in five members received a general medical exam during the year. The age range is when many chronic conditions begin to appear and when early detection of a condition can significantly reduce long-term problems. The second most likely age group is the 45 to 54 age range, in which 18.5 percent of members received a general medical exam. Pediatric members had much higher rates. Almost 42 percent of all members under the age of 18 had a routine child health exam in Routine Medical Exams AGE CATEGORY MEMBERS TOTAL MEMBERS % TOTAL MEMBERS , , % , , % , , % , , % ,645 68, % , % , % Health Exams: Conclusions Overall, the most common reasons BCBSNC members sought medical attention in 2002 were for preventive care which bodes well for detecting problems that could lead to chronic conditions. However, these results are tempered by the fact that only one in eight members received a general medical exam during the year. Women are far more likely to have a preventive health encounter with a physician, and most often, these are with an OB/GYN provider. Health interventions designed to increase preventive care should take into account the frequency with which adult female patients visit a gynecologist and should include OB/GYN providers as a target audience. For many reasons, women historically have embraced preventive health care more readily than men. There is, however, considerable room for improvement even for women especially with getting regular preventive health exams. For men, much work remains to encourage them to visit a doctor for preventive health exams and screenings. Health policy experts, physicians, health plans and others with a stake in health care have a responsibility to develop strategies to increase the likelihood of men going to the doctor other than when they re sick. The State of Preventive Health 5

8 Section 2: Preventive Health Attitudes and Actions In 2001, BCBSNC asked a sample of its members a variety of questions on their attitudes about preventive health. The survey identified barriers to obtaining preventive care and determined how members preferred to receive health information. Failed to Receive Preventive Health Exam REASON PERCENTAGE OF RESPONDING MEMBERS* I m healthy 31.1% I don t have a regular doctor 21.1% I feel fine 9.5% I never thought about it 8.7% I m too busy 6.7% Failed to Receive Blood Pressure Test REASON PERCENTAGE OF RESPONDING MEMBERS* I feel fine 43.1% I m healthy 27.8% I never thought about it 25.0% I don t have a regular doctor 22.9% I was tested more than one year prior 22.9% * Members could cite more than one reason Three-fourths of responding members said they had seen a physician in the last 12 months. Among women reporting that they had seen a doctor, two-thirds said it was an OB/GYN visit. However, when asked about preventive care, a high proportion of members reported that they did not get a preventive health exam or screening within the past year. These members cited several reasons why they received no such preventive care: They were healthy. They felt fine. They never thought about getting an exam or screening. Members also were asked to rate their preferred methods of receiving health information. If information about preventive care comes through preferred channels, consumers are potentially more likely to act on that information. The role of the physician was illuminated in the survey. Members reported that their doctor is the preferred source of information more often than any other source. As for communication vehicles, members are more interested in written materials mailed to them, followed by articles in magazines or newsletters. Health information received by telephone ranked last. 6 November 2003

9 When asked about preventive care, a high proportion of members reported that they did not get a preventive health exam or screening within the past year. The State of Preventive Health 9

10 Preferred Sources of Health Information SOURCE WEIGHTED INDEX SCORE* Physician 4.59 Other health professional 4.03 Medical organization 3.58 Pharmacist 3.52 BCBSNC 3.50 Family 2.75 Friends 2.41 Co-workers 2.28 Preferred Channels of Health Information SOURCE WEIGHTED INDEX SCORE* Written materials mailed to member 3.89 Articles in magazines/newsletters 3.57 Articles in daily newspapers 3.27 Television 3.10 Worksite 2.95 Internet 2.84 Radio 2.48 Telephone 1.79 *Based on average preference values, with 5 as most preferred and 1 as least preferred Preventive Health Attitudes: Conclusions Members who appear to be complacent about their health the ones who say they are healthy or feel fine are potentially in greater danger of serious health problems. An ignorance is bliss attitude about one s health often leads to serious consequences: Hypertension, colon cancer and some forms of heart disease often develop without any symptoms, striking before the patient is even aware there s a problem. Physicians, who are in the best position to influence a patient s behavior, should have all the information they need to counsel their patients about preventive care and healthy lifestyle choices. When possible, health plans should partner with doctors to provide and tailor the right information that could benefit the health plan member. 8 November 2003

11 Section 3: Healthy vs. Unhealthy Behaviors The importance of healthy lifestyle choices cannot be overstated. According to the Centers for Disease Control and Prevention (CDC), a third of all deaths each year in the United States are attributed to poor eating habits, lack of physical activity and tobacco use. North Carolina tends to fare worse than national averages on these health indicators. Almost 26 percent of North Carolina adults smoke, compared with 23 percent nationally. And 23 percent of the state s adults are obese; the national rate is 21 percent. In its 2002 report card on the state s preventive health, N.C. Prevention Partners issued an F for nutrition, F for physical activity and D-minus for tobacco use. With few adults getting enough physical activity, a lack of nutrition programs, and the nation s third lowest cigarette taxes, North Carolina has serious shortcomings in preventive health, the organization concluded. Current Smoking Rates for North Carolina and U.S.* Percentage of Population 30% 25% 20% 15% 10% 5% 28.0% 26.4% 27.8% 25.9% 25.9% 23.9% 23.0% 23.1% 22.2% 22.6% 22.7% 22.4% 25.7% 25.8% 24.6% 25.1% NC US 26.1% 23.4% 23.2% 22.9% 22.6% 23.2% 25.7% 22.8% 0% Year Adult Obesity Rates for North Carolina and U.S.* Percentage of Population Obese (Body Mass Index 30+) 25% 20% 15% 10% 5% 0% 21.5% 21.8% 16.9% 18.1% 18.3%19.4% 19.7% 20.1% 15.7% 16.3% 18.3% 13.4% 12.9% 13.4% 15.8% 16.8% 16.6% 13.7% 14.4% 12.6% 12.6% NC 11.6% US Year 22.9% 21.0% * Centers for Disease Control and Prevention The State of Preventive Health 9

12 Changing the behavior of millions of people is a huge undertaking, but one worth the effort. 12 September 2003

13 % of 2003 enrollees 80% 70% 60% 50% 40% 30% Obesity Among Health Improvement Program Participants % obese (Body Mass Index 30+) % overweight (Body Mass Index 25-29) 53% 71% 71% Obesity and being overweight often are linked to chronic conditions such as diabetes. Among BCBSNC members who participate in health improvement programs offered by the company, obesity was prevalent most frequently with diabetes and congestive heart failure. In fact, with both programs, 71 percent of participating members were identified as either obese or overweight. These findings are in line with national studies showing the presence of obesity with chronic health conditions. 20% 10% 0% Asthma Adult Congestive Heart Failure Diabetes Program Health Behaviors: Conclusions Unhealthy lifestyles represent an enormous burden, both in terms of the effect on individuals and the costs to treat chronic health problems. Sadly, the problem isn t limited to adults. Up to 15 percent of school-aged children are now obese, so efforts to curb this problem should start early. For example, programs targeting new parents could encourage them to help their children adopt healthy lifestyle choices at an early age. The CDC has identified several areas where investments in prevention can be expected to make a significant impact on health. These include: getting regular physical activity to control weight and reduce the risk for heart attack, colon cancer, diabetes and high blood pressure; increasing consumption of fruits and vegetables to reduce the risk for heart disease and certain types of cancer; and quitting smoking, which after 10 years reduces the chances of getting lung cancer to half that of a current smoker. Changing the behavior of millions of people is a huge undertaking, but one worth the effort. The State of Preventive Health 11

14 Section 4: Impact According to the CDC, two-thirds of U.S. deaths each year can be attributed to just five chronic diseases heart disease, cancer, stroke, chronic obstructive pulmonary disease and diabetes. An estimated 125 million Americans live with chronic conditions, many of which are often treatable but not curable. In 2002, BCBSNC spent about $85 million on claims for these five diseases alone. On a per-member basis, three of the company s eight most costly conditions to treat fall within these disease categories breast cancer, chronic ischemic heart disease (in which the heart does not get enough oxygen-rich blood) and heart failure. Chronic ischemic heart disease also ranked as the company s second most costly diagnosis in terms of total spending. Top Diagnoses by Average Paid Per Member RANK PRIMARY DIAGNOSIS DESCRIPTION MEMBERS CLAIMS PAID PAID PER MEMBER 1 Complications of Device, Implant, Graft 1,701 5,067 $9,286, $5, Female Breast Cancer 2,829 54,470 $10,596, $3, Cholelithiasis (gallstones) 2,923 6,057 $9,597, $3, Other Chronic Ischemic Heart Disease 8,750 38,276 $25,664, $2, Other Surgical Complications 1,660 3,124 $3,560, $2, Abnormal Pelvic Organ in Pregnancy 1,526 3,122 $3,250, $2, Perineal Trauma With Delivery 1,941 2,348 $3,991, $2, Heart Failure 1,820 7,447 $3,631, $1, Endometriosis 1,879 5,742 $3,314, $1, Single Live Birth 6,730 7,401 $11,725, $1, Top Diagnoses by Total Paid* RANK PRIMARY DIAGNOSIS DESCRIPTION MEMBERS CLAIMS PAID PAID PER MEMBER 1 Respiratory System/Other Chest Symptoms 59, ,122 $31,975, $ Other Chronic Ischemic Heart Disease 8,750 38,276 $25,664, $2, Other Abdomen/Pelvis Symptoms 46, ,484 $19,988, $ General Symptoms 65, ,548 $19,402, $ Intervertebral Disc Disorder 13,533 88,815 $16,646, $1, Back Disorder 43, ,755 $14,887, $ Special Examinations 118, ,162 $13,485, $ Aftercare 23,844 83,306 $12,045, $ Single Live Birth 6,730 7,401 $11,725, $1, General Medical Exam 87, ,400 $11,407, $ * Among 250 Most Frequently Occurring Diagnoses 12 November 2003

15 In 2002, the two most expensive inpatient hospital diagnoses for BCBSNC, on a per-member basis, were acute myocardial infarction (heart attack) and other chronic ischemic heart disease. Each heart attack cost BCBSNC an average of $14,430, while each hospitalization for ischemic heart disease was $14,135. Significantly, these two categories were male-dominated: roughly three quarters of all heart attack and ischemic heart disease hospitalizations were for men. Percentage 100% 75% 50% 25% 0% Cardiac Hospitalizations by Gender 23.3% Acute Myocardial Infarction 76.7% 75.3% Diagnosis 24.7% Other Chronic Ischemic Heart Disease Female Male Impact: Conclusions After decades of medical research, it s clear that many cases of these costly, chronic diseases are largely preventable. And even if chronic disease does develop, it can be far more effective and less costly to treat if detected early. A prime example is cardiovascular disease. Healthy lifestyle choices help prevent heart problems, and regular screenings, especially after age 40, help detect the onset of heart disease. If left undetected and untreated, the results can be devastating. The State of Preventive Health 13

16 Recommendations Encouraging North Carolina residents to engage in preventive health behaviors is essential if the state is to see a reduction in the rate of chronic diseases and health problems. As identified in this report on preventive health measures by Blue Cross and Blue Shield of North Carolina members, not enough North Carolinians especially men are receiving regular preventive health exams and screenings. Too many are being treated for chronic, expensive health conditions that in some measure could be prevented or at least detected early. And too large a proportion of the state s population is engaging in unhealthy behaviors. Considerable work must be done to educate North Carolinians on good preventive health. But the task is not impossible. To further the dialogue with this initial report on preventive health, BCBSNC issues the following recommendations for health policy experts, physicians, health plans and others to take: Encourage more North Carolinians particularly men to obtain regular health examinations and screenings appropriate for age and known risk factors, and more lifestyle counseling and support. Promote physical activity, healthy eating habits and a tobaccofree lifestyle. Expand participation in health improvement programs around heart disease, respiratory disease and diabetes to enable those with chronic conditions to live healthier lives and to prevent a worsening of these conditions. Focus efforts on children starting as early as preschool ages to show them how to eat healthy and get regular physical activity. 14 November 2003

17 Encouraging North Carolina residents to engage in preventive health behaviors is essential if the state is to see a reduction in the rate of chronic diseases and health problems. The State of Preventive Health 17

18 Preventive Health Programs from Blue Cross and Blue Shield of North Carolina Preventive Care Guidelines Goals and guidelines for member preventive care are detailed in BCBSNC s medical policy, available on the company s Web site at Preventive care guidelines are based on clinical guidelines established by the American Medical Association, Centers for Disease Control and Prevention and other medical and health bodies. BCBSNC measures preventive care outcomes among its membership under national Health Plan Employer Data and Information Set standards and participates in the annual accreditation process established by the National Committee for Quality Assurance. Men s Health Initiative BCBSNC developed a men s health project to increase the proportion of male members ages 40 to 60 who see their primary care provider for preventive care services. The company examines claims data from its HMO and POS population to identify men who have visited the doctor for illness or injury, but have not had a physical exam in the previous three years. BCBSNC then sends the primary care doctor a set of chart stickers to place on the member s medical chart to serve as a reminder to schedule a physical or screening, and sends information on health screenings to the member. The program was piloted in 2002 and expanded in Women s Health Initiative The women s health initiative is designed to encourage women to seek regular health screenings and to provide health education. For members, BCBSNC sends birthday reminder postcards encouraging annual Pap smears and mammograms. For providers, the company provides education, including a breast health education tool kit to physicians scoring lower than their peers for breast cancer screenings. Providers also receive chart stickers to serve as reminders for Pap tests, mammograms and menopause counseling. Heart Health Initiative In spring 2003, BCBSNC launched two new health improvement programs aimed at helping members with cardiovascular disease manage their conditions, prevent further damage and live healthier lives. Your Heart Matters SM is for members with congestive heart failure. Members receive a variety of tools and educational materials. And Heart Beats SM is a targeted program for members the company has identified as having had a recent cardiac event, such as a heart attack. The program helps patients control their cholesterol levels and offers assistance with making behavioral changes. Cardiac Care Reports BCBSNC generates and sends a prospective report to all primary care and cardiac providers listing members who had an acute cardiovascular event (heart attack, by-pass, or angioplasty) in the past year and who are due for cholesterol screening in the coming year. The company also provides retrospective reports to providers who have non-adherent hypertension and hyperlipidemia patients, or who are prescribing less than optimal therapy to treat their patients for high blood pressure or high cholesterol (managed by Merck-Medco Managed Care, L.L.C.). Behavioral Health Initiatives BCBSNC offers a variety of programs to help members who are diagnosed with depression. For example, the company s antidepressant medication compliance program is designed to optimize the care of members who are new to treatment. To help them understand the importance of compliance with medication, newly diagnosed members are sent an educational letter, stress reduction tips and refill reminder stickers to place on a calendar. The company notifies prescribing physicians if the member fails to refill the medication within the expected time frame. On request, the company also provides to physicians an internally developed algorithm with guidance on risk factors, signs and symptoms, treatment options and key messages for patients. Blue Points SM Blue Points provides incentives for BCBSNC members to engage in physical activity. Launched in 2000, Blue Points encourages spending 30 minutes a day in a physical activity and offers prizes for participation. Members visit the company s Web site to log their activity and receive points and are eligible for prizes when reaching certain points milestones. A separate Blue Points for Kids SM program offers prizes for children for physical activity. Get Fit Blue SM BCBSNC offers discounts and information on nutrition and fitness products, programs and services under Get Fit Blue. Discounts of 40 to 50 percent are available for approved weight-loss programs. Additional products and services such as scales, heart rate monitors, nutrition counseling and personal training are also eligible at a discounted rate. Be Active North Carolina and Be Active Kids BCBSNC serves as the founding sponsor for Be Active North Carolina, which aims to increase physical activity across the state, and for Be Active Kids, which targets 4- and 5-yearolds with lessons about physical fitness and good nutrition. 18 September 2003

19 Innovative health care designed around you ṢM bcbsnc.com 20 September 2003 An independent licensee of the Blue Cross and Blue Shield Association PO Box 2291 Durham, NC / Registered Mark of the Blue Cross and Blue Shield Association SM Service Mark of the Blue Cross and Blue Shield Association