THIS CASE RELATES TO CHAPTER 4

CASE STUDY: OBESITY AND DIABETES QUALITY AND HIGH COST CONDITIONS REQUIRING ACTION BY MANAGED CARE COMPANIES.

The obesity epidemic affects every state, according to a new CDC report. No state met the country's Healthy People 2020 goal to lower obesity to 15 percent. The report also makes recommendations on how to reverse the epidemic.

The CDC Vital Signs report, titled "State-Specific Obesity Prevalence Among Adults United States, 2009," points out that people who are obese incurred $1,429 per person extra in medical costs compared to people of normal weight, and that the nation's total medical costs of obesity were $147 billion in 2008.

Obesity affects some communities more than others. The highest rates were found among non-Hispanic blacks overall, whose rate was 36.8%, and non-Hispanic black women, whose rate was 41.9%. The rate for Hispanics was 30.7%, and the rate among all non-high school graduates was 32.9%. In addition, the obesity rate was higher in some regions of the country than others. Midwesterners had a rate of 28.2% and residents of the South were at 28.4%.

If you look at the health problems linked to obesitythe costs are even greater. One major chronic illness that seems to be affected by obesity is diabetes. 2011 data from the American Association of Diabetes indicate that 25.8 million children and adults in the United States 8.3% of the population have diabetes. The total cost of diagnosed diabetes in the United States in 2007 amounted to $174 billion. Adults with diabetes are more likely to have strokes and heart disease than those without diabetes.

THE CEO OF THE XYZ MANAGED CARE COMPANY (MCO) JUST READ THESE REPORTS FROM THE CENTERS FOR DISEASE CONTROL (CDC) AND THE AMERICAN ASSOCIATION OF DIABETES. THE CEO HAS ASKED YOU THE VICE PRESIDENT OF UTILIZATION MANGEMENT (UM) , QUALITY MANGAGEMENT (QM) TO DEVELOP AN ACTION PLAN THAT WOULD 1. IDENTIFY MEMBERS AT RISK FOR OBESITY AND DIABETES AND 2. OUTLINE STEPS TO MANAGE HIGH RISK MEMBERS.

ASSIGNMENT: IN A FOUR PAGE DOUBLE SPACED TYPED PAPER INDICATE HOW YOU WOULD USE UTILIZATION MANAGEMENT (UM), QUALITY MANAGEMENT(QM) AND ANY OTHER STRATEGY FROM THE TEXTBOOK TO DEVELOP THIS PLAN. YOU WANT TO BE PRO-ACTIVE TO PREVENT AN INCREASE IN MEDICAL COSTS WHICH COULD IMPACT YOUR COMPANIES COMPETITIVE EDGE AND YOU WANT BE ACCREDITED BY THE NATIONAL COMMITTEE ON QUALITY ASSURANCE (NCQA)BY MEETING THEIR CURRENT HEDIS MEASURE REGARDING TYPE 2 DIABETES IN CHILDREN.

NOTE: Claims is not only used to reimburse (pay) providers when they submit a claim, but can also be used to gather data on all their members since the demographic, diagnostic, name of provider etc is on the claim. For example if you need to know how many members in zipcode 10032 are age 16 and had a diagnosis of asthma you could request such a report from claims.