Executive Summary
This project aims to collect relevant data related to chronic condition management. The topic of this project is chronic disease management and the problem is that Anthem has 85% of diabetes readmission rates while the national standard is set at 56.8%. Data review will be done by examining empirical research on chronic condition management. The nature of the findings will allow Anthem to invest in quality improvement initiatives that will help enhance diabetes management practices and reduce reimbursement payments.
Introduction
I am examining chronic disease management because currently, readmission rates for diabetes are estimated at 85% despite the standard set at 56.8% (AHRQ, n.d.). I will examine empirical data and will assess the data by measuring hospitalization rates due to complications, readmissions within 30 days, self-reported quality of life. The project will add value to Anthem by improving quality of disease management and minimizing costs associated with it. This project aligns with my professional and career goals because it enhances my understanding of process improvement and its impact on patient’s lives.
Chronic conditions are an increasing concern globally because they affect a large population of people both worldwide and in the US. However, one element of these conditions is the fact that they can be prevented or successfully managed at home by patients without a need to continuously visit hospitals. For Anthem as an insurer, such practice can lead to a significant improvement of the company’s bottom line because of a decrease in reimbursement payments provided to medical establishments for their services. This paper aims to outline the framework for examining relevant data, explain how the project adds value in four areas of the balanced scorecard, and propose a method for visual display of raw data.
Statement of the Problem
85% of Anthem’s patients who have diabetes were readmitted within a year when compared to a benchmark of 56.8% set by the Agency for Healthcare Research and Quality (AHRQ, n.d.).
Background
Literature evaluation was performed to determine the scope of the issue. Rubin (2015) focuses the research on readmission rates connected to diabetes, which corresponds with the aim of this project. Chronic conditions result in vast financial spending within the industry and the issue will continue to burden the health insurance sector. Chouvarda, Goulis, Lambrinoudaki, and Maglaveras (2015) and Milani and Lavie (2015) offer new models of care that will help improve patient outcomes. In the context of this paper, these findings will help shape the quality improvement strategy that can be implemented by Anthem.
Wallace, Smith, Fahey, and Roland (2016) offer strategies for reducing readmission through community programs, which contributes to the understanding of this problem. In essence, these resources cite that over 70% of costs within healthcare are associated with chronic conditions, and the current trend is to implement strategies of self-management.
Next, the following sources were examined to determine the consequences of not addressing chronic disease management in regards to Anthem’s revenue. Ostling et al. (2017) and Hicks et al. (2016) provide valuable information regarding the prevalence of diabetes and implications of readmission rates, that help this project by providing relevant data about the burden of diabetes for health establishments. This source relates to the topic because it provides a description of readmissions and specifics of diabetes management.
Self-management is recommended as a viable strategy for improving the quality of life for people with diabetes, which can affect the performance criteria assessed in this project, such as readmissions and complications. The American Diabetes Association (2018) developed the Standards of Medical Care in Diabetes guide that summarizes evidence form a variety of sources in regards to treating and managing diabetes.
The organization acknowledges the effect that social and economic factors have in the process of management and self-management. According to the American Diabetes Association (2018), despite the significant improvement seen in the notable indicators of health for the population in question, approximately 33% to 49% still do not meet the target measures for “glycemic, blood pressure, or cholesterol control” (p. 1).
Moreover, only 14% are able to meet all three criteria and avoid smoking, which is a significant concern. Based on this data and the recommendations from Anthem, the project’s target measures were updated to incorporate the information about the percentage of people ignoring or being in denial of their condition to have an enhanced understanding of the issues that contribute to the inadequate diabetes management.
Client Value Proposition
The framework chosen for investigating the type of data that will be examined within this project is a balanced scorecard, which is presented in Table 1. Due to the fact that this proposal outlines a new service line that will be a part of Anthem’s services, an approach that helps define the benefits of this novel model is required. Behrouzi, Shaharoun, and Ma’aram (2014) state that because of “changing demands on business due to many internal and external changes in the healthcare industry, it is argued that the key to achieving the targeted level of performance is to adopt new approaches of performance measurement” (p. 209). In addition, balanced scorecards dedicate specific attention to performance indicators, which are crucial for this project and measurement of outcomes.
Thus, by using the framework of the balanced scorecard Anthem will be able to leverage the implications of this project and mitigate the constraints by linking this outline with core business elements. Kaplan and Norton (1996) state that a balanced scorecard incorporates a variety of non-financial indicators, including performance measures that present a better understanding of the company’s activity. Thus, the criteria based on which the choice of the framework was made are applicability in regards to the purpose of the chronic disease management project, availability of essential performance indicators that allow assessing the outcomes, and ability to connect the data with the business processes of Anthem.
This chronic condition management project addresses and adds value in all four areas of organizational balanced scorecard by improving business operations through an introduction of a new service line, which is also helpful in the domain of organizational learning and growth. The financial aspect will benefit because of the increase in revenue and customer service should see an enhancement of satisfaction rates because of a new product that improves the quality of life for patients. This is substantiated by Chouvarda et al. (2015) who argue that technology can be a driving force behind significant changes in healthcare and more specifically in the means of addressing chronic conditions. The authors cite personal health systems as a new strategy for addressing healthcare issues, which are the focus of this proposal.
As for the value that this project will provide to Anthem in regards to the financial benefits, it should be noted that according to Milani and Lavie (2015) over 75% of reimbursements in the US are dedicated towards chronic disease care. The authors state that currently the healthcare system is unprepared to efficiently manage this issue, which creates an ability to gain a competitive advantage over those that fail to address chronic disease care. Evidence, such as an article by Milani and Lavie (2015) and Chouvarda et al. (2015) suggest that Anthem has to pay more attention to the issue of chronic condition care. The data management and analytics that are a part of this process will help the company significantly improve its operations.
From a strategic perspective, better management of chronic conditions will relieve the burden associated with hospitalization of patients that can manage their disease at home, for which Anthem has to pay a provider. From a systems perspective, the healthcare industry in the US requires changes that would both access, which involves innovation from healthcare organizations. Chouvarda et al. (2015) insist on a need for changing the current strategies to meet the increasing number of patients with chronic conditions. Adequate chronic condition care requires the involvement of a patient in the process of monitoring and reporting his or her health state.
Additional information that can strengthen the value proposition is data illustrating the burden of chronic diseases on health insurers in the US, which would help substantiate the need for further examination of relevant data. All in all, this project aligns with the mission and vision of the organization because it offers an innovational strategy for managing chronic conditions, which will significantly improve the lives of patients. Anthem should provide input into this project by assisting with data collection and presenting feedback to ensure that performance indicators align with the needs of the company.
A lot of evidence suggests that the issue of diabetes has already affected the available healthcare resources. The American Diabetes Association (2018) states that from 2012 until 2017, the economic burden of this chronic condition rose by 26%. This is attributed to two major factors – an increase in the number of patients who were diagnosed with diabetes and growth of costs per patient associated with management. The organizations emphasize the role of self-management as vital in the process of effectively addressing chronic conditions such as diabetes. By collecting the proposed data, together with additional age group information, Anthem will have a comprehensive assessment of the issue and its impact on the organization, including financial losses.
Table 1. The balanced scorecard (created by the author).
Expected Outcomes and Precise Performance Measurement
A proposed structure for visual data display, in this case, is a histogram graph because it will allow one to compare all three criteria of Anthem with benchmark data in one screen. Graph 1 presents the histogram displaying the currently available information about hospital admissions and will be completed in the final stages of this project. Performance indicators are number of people engaged in the management program and their hospital visits over a year. Units of measurement are patients and the number of hospitalizations, while the time frame is one year. Type of organization in question is a for-profit health insurance company operating in the United States – Anthem. Thus, the proposed title is as follows – examining the number of Anthem’s clients who use technology to improve their chronic disease management over a year.
While the primary assessment criteria will include readmissions due to complications, self-reported quality of life, and hospitalizations because of diabetes complications. In addition, in order to have a better understanding of the impact that this chronic condition has on individuals and the specifics of their adherence to the recommendations of their providers regarding management, the participants will be divided into age groups. The criteria that will help identify this is a denial of the disease or ignoring the process of its development, socio-economic issues, and the aging process. The visual that will help represent this data is a graph, and Graph 2 provides an example of this method. The Benchmark data will be collected from organizations such as AHQR and scholarly articles that assess the self-reported quality of life targets for diabetes patients.
The data assessment measurements outlined above significantly improve the scope of this project. The inclusion of these elements is substantiated by the American Diabetes Association (2018) according to which providers have to assess the social context that affects their patients as well as health indicators. For instance, aspects such as food insecurity, housing, and financial issues have an impact on the course of management.
According to Blair (2019), is an essential part of chronic condition management, including diabetes, and this project will be able to indirectly assess the impact of this innovation. Although this is not a part of performance measurement, Anthem has a telehealth program and the results of the evaluation can help enhance it. In addition, the author provides a better understanding of the impact that denial or purposeful ignoring of the disease progress because the presented evidence suggests that interventions such as nutrition change are crucial in avoiding complications.
Recommendation such as increased water intake and avoidance of sweetened drinks, even those manufactured with nonnutritive sweeteners, is another example of the deliberate intervention necessary for adequate management. This evidence suggests that people diagnosed with diabetes have to pay attention to their lifestyle, which is impossible when denying the condition. Thus, it can be hypothesized that in age groups with a significant percentage of people with these criteria, the number of readmissions and complications will be higher.
Leadership Component
My responsibilities in leading the effort consist of assessing Anthem’s data and comparing it to the national standard. Within the Execution domain, I will practice the competency of change leadership by accessing information from different individuals and actively seeking feedback. With Transformation, I will practice result orientation by aiming to provide Anthem with a valid solution to the chronic disease management problem. In the domain of People, I will practice professionalism by thoroughly researching the topic and communicating with people working in this industry.
Timeline
Table 2. Timeframe for the project (created by the author).
Project Information
- On site contact
- Personal contact information
- Instructor’s contact information
- Statement of confidentiality
- Signatures.
References
The American Diabetes Association. (2018). Standards of medical care in diabetes—2019 abridged for primary care providers. Clinical Diabetes, 37(1), 11-34. Web.
Anthem better prepared diabetes care program. (n.d.). Web.
AHRQ. (n.d.). Diabetes quality measures compared to achievable benchmarks. Web.
Behrouzi, F., Shaharoun, A. M., & Ma’aram, A. (2014). Applications of the balanced scorecard for strategic management and performance measurement in the health sector. Australian Health Review, 38(2), 208–217. Web.
Blair, A. M. (2019). American Diabetes Association standards of medical care in diabetes – 2019 [Power Point Presentation]. Web.
Chouvarda, I., Goulis, D., Lambrinoudaki, I., & Maglaveras, N. (2015). Connected health and integrated care: Toward new models for chronic disease management. Maturitas, 82(1), 22-27. Web.
Healthy generations. (n.d.). Web.
Hicks, C. W., Selvarajah, S., Mathioudakis, N., Sherman, R. E., Hines, K. F., Black, J. H., & Abularrage, C. J. (2016). Burden of infected diabetic foot ulcers on hospital admissions and costs. Annals of Vascular Surgery, 33, 149–158. Web.
Kaplan, R. S., & Norton D. P. (1996). Using the balanced scorecard as a strategic management system. Harvard Business Review, 74(1), 75–85.
Milani, R., & Lavie, C. (2015). Health care 2020: Reengineering health care delivery to combat chronic disease. The American Journal of Medicine, 128(4), 337-343. Web.
Ostling, S., Wyckoff, J., Ciarkowski, S., Pai, C., Choe, H., Bahl, V., & Gianchandani, R. (2017). The relationship between diabetes mellitus and 30-day readmission rates. Clinical Diabetes and Endocrinology, 3(1), 1-8. Web.
Rubin, D. (2015). Hospital readmission of patients with diabetes. Current Diabetes Reports, 15(4), 5-9. Web.
Wallace, E., Smith, S., Fahey, T., & Roland, M. (2016). Reducing emergency admissions through community based interventions. BMJ, 352(6817), 1-7. Web.
Addendum
The healthcare professional who can provide substantial feedback based on Anthem’s operational objectives and strategic plan is a senior manager, Amanda Hemiup, who works as an FEP Branch Director. When preparing for the project, professional communication was researched and to ensure that the proposal is a viable and realistic personal experience and NCHL competencies were assessed. The conclusion is that the benchmark data can be collected from national agencies, and Anthem will be able to assist with collecting other information.
The meeting took place on July 17, 2018, and involved a brief presentation of the project, evidence supporting the need for the data collection, and benefits that the company would obtain. The overall purpose of the project as a learning activity at Capella University’s Master’s program and my role as a leader in this project was also explained.
The meeting revealed that Anthem is indeed interested in improving its diabetes care. For instance, Better Prepared Diabetes Care Program was introduced to clients to provide them with information, necessary tools, and access to nurse consultations (“Anthem better prepared diabetes care program,” n.d.). The idea was to improve the quality of people’s lives and enhance health by educating and assisting them.
Additionally, the Healthy Generation Program targets diabetes prevention among other healthcare concerns by addressing social determinants of health (“Healthy generations,” n.d.). One of the strategies that the project applies is population data analysis, which is consistent with the objective of this project. The client had questions regarding the value of this project and possible implementation strategies that Anthem can use.
No alterations to the project’s scope or execution were suggested, although the client advised on broadening the focus. The primary changes that were proposed to this project were the assess other criteria to have a better understanding of different factors contributing to high diabetes readmission rates. Thus, age groups and specific impact associated with them can improve the analysis and will help improve management practices. Aspects such as the aging process, socio-economic issues, denial, or ignoring the disease process can provide valuable insight into the problem and are included in the updated project proposal. These changes are feasible and will help improve the analysis of chronic condition’s management.
Some changes were made to the literature review, and more resources that discuss management practices specific to diabetes care were added.
In order to ensure that the project is a collaborative effort and no violations of Anthem’s policies confidentiality was disused, and it was agreed that it is my responsibility as a leader to ensure that the data is collected in accordance with standards, both legal and ethical. Overall, the performance indicators and outcomes measures were updates following the recommendations, and approval for this project was obtained.