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Home-based care program also benefits the insurer

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Times Staff Writer

Every year, about 1.5 million Americans are diagnosed with cancer. Every year, they run up a medical tab estimated at $100 billion.

Some of that money is spent on unnecessary hospitalizations and emergency room visits, which is why Blue Shield of California sends a nurse to Pamela Sprott’s home in Valencia several days a week.

“I am not in the hospital because she makes sure I am taken care of,” Sprott, 56, said of the care coordinator who keeps track of her mind-boggling regimen of chemotherapy treatments and drug prescriptions and the appointments with specialists who treat her leiomyosarcoma, a rare form of cancer that started in her uterus.

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Supplying care coordinators is one of Blue Shield’s strategies to prevent patients’ conditions from worsening while containing the costs of treatment. By vigilantly managing Sprott’s treatment, the insurer lowers her risk of developing complications, such as dehydration or anemia, that could land her in an emergency room or hospital bed.

“What we are saying is, let’s just keep the bad stuff from happening in the first place,” said Andrew Halpert, Blue Shield’s senior medical director.

A Blue Shield study published in the American Journal of Managed Care found that patients like Sprott had 30% fewer emergency room visits and 38% fewer hospital admissions than Blue Shield cancer patients who didn’t receive the intensive care coordination.

The study, co-authored by Halpert, concluded that the care-coordination program, launched on a trial basis in 2003, saved more than $18,000 per patient on average in an 18-month period. Survival rates remained virtually the same.

Blue Shield, which with 3.2 million members is the third-largest health plan in California, rolled out the patient-centered management program statewide this year to about 800 patients with late-stage cancer and other serious diseases. The insurer hasn’t disclosed the cost of the program, but the study concluded that the trial had a return-on-investment ratio of 2 to 1.

Most health plans have call centers with customer service representatives who answer members’ questions about their coverage and help them find specialists, among other things. But the service isn’t personalized.

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At Blue Shield, each coordinator handles no more than two dozen patients, and they are regularly visited at home.

A chief goal of the program is to keep people out of hospitals, and especially emergency rooms. Patients who land in the ER are likely to be seen by a doctor with little or no background in oncology, said Thomas B. Strouse, the director of pain management at the Cedars-Sinai Outpatient Cancer Center in Los Angeles. That is no good for the patient or the insurance company paying most of the bill.

The idea of decreasing hospitalization to rein in healthcare costs isn’t new. For a decade, Kaiser Permanente, the state’s largest health maintenance organization, has offered intensive home-based treatment to some of its sickest patients, including cancer sufferers.

The end-of-life care saved about half the costs of treating such patients without the program, according to Kaiser, which plans to double the number of Southern California patients who receive care at home to 2,000 this year.

Avoiding costly hospitalizations is increasingly important for insurers, said Michael Burcham, president of ParadigmHealth Inc. of Upper Saddle River, N.J., which specializes in care coordination for complex cases that include cancer, neo-natal and spinal cord patients. The company, whose clients include Blue Shield, has seen its business grow 20% to 25% a year since 2002.

“If you look at the elderly population, hospitalization is a significant piece of the cost,” Burcham said. “As the baby boomers age, we will be facing more of these cases.”

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Beyond that, patients who remain at home tend to feel more comfortable with their treatment regimen than patients in hospitals.

Len Lichtenfeld, deputy chief medical officer for the American Cancer Society, welcomes the trend. But echoing many patients’ advocates, he cautions that such decisions should be based on medical evidence, not cost concerns.

Blue Shield executives said their program was designed to avoid unnecessary treatment rather than withhold what’s needed.

Health insurers’ attempts to cut costs have often met with accusations that the savings come at the expense of care. Denial of requested treatment is one of the most common complaints that clients lodge, according to the California Department of Managed Health Care. The state received 1,080 such complaints last year, 524 of them against San Francisco-based Blue Shield. The nonprofit health plan is also among a handful of California insurers to be sued by patients saying they were dropped once they became ill and accumulated large medical bills. Blue Shield and the others have denied wrongdoing. Sprott, a former teacher who’s married to Robert Sprott, a Superior Court judge, is undergoing chemotherapy and trying not to think about her life ending. The couple have a 15-year-old son.

A few years ago, before she learned she had cancer, she was in a serious car accident.

“The car rolled over three times,” she said. “I thought I was going to die then. I don’t know that I’ll die of cancer. It might be something else, but you just have to take one day at a time and enjoy the day.”

daniel.yi@latimes.com

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