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By MATT WICKENHEISER, Staff Writer Tuesday, May 8, 2007

When Sandra Davis learned last May that she had diabetes, she knew who to call for more information on her condition and how to deal with it: her health insurance company.

The Falmouth resident had been assigned a nurse case manager by Anthem Blue Cross and Blue Shield in the fall of 2002, when she was diagnosed with cancer. The manager, Bertha Porter, "was a wonderful resource," said Davis. Whenever Davis had medical questions about her cancer treatments, she could call Porter. So when diabetes entered the picture, the call to Porter was a natural.

"She just gave me very good advice on the types of foods that I would eat that would be best," said Davis. "She just made things a lot clearer for me. I got instant answers to every question I had."

In recent years, Anthem parent company WellPoint Inc. has pushed beyond the traditional insurance role of mere bill payer. The company, which is Maine's largest health insurance provider, provides managers like Porter for clients with chronic conditions. It uses its broad databases of client information to spot instances when clients aren't getting the type of medical care or tests they should -- and then brings it to their attention.

"We can see you might be taking medicine to lower cholesterol, but not doing the right screening for (liver), or you have diabetes and you have not seen an ophthalmologist. All of those are gaps in care," said Dr. Sam Nussbaum, executive vice president and chief medical officer at WellPoint. "You're only getting the best care that American medicine can offer 55 percent of the time. We fill the gap."

Last month, WellPoint took that assertion to a different level. The company unveiled its Member Health Index initiative, a complex set of measurements and algorithms designed to measure how the company's programs have managed care and improved the "health and wellness" of its members.

The MHI is made up of 20 clinical areas that reflect quality of care. The areas can be broken down into four categories: prevention and screening, care management, clinical outcomes and patient safety. As part of WellPoint, Anthem is running the program here.

And 5 percent of all of WellPoint's employees' annual bonus will be based on that measurement.

"We're the first and only company to basically reward our 45,000 associates based on how we move the needle on the health of our members," said Nussbaum.

WellPoint is carving out a very important role for itself using analysis of claims data to improve clients' health, suggested Paul Ginsburg, president of the Center for Studying Health System Change, a nonpartisan policy research group based in Washington, D.C.

"This is an important augmentation of traditional insurer roles of processing claims and avoiding paying for services that are not necessary," said Ginsburg. "Many of the measures involve making sure that important care was provided and intervening when it is not."

Nussbaum said WellPoint measures optimal care for different medical conditions. And it can use the claims filed -- or not filed -- to see of that optimal care is being provided.

For instance, Nussbaum explained, through medical claims, the company would know if a client was being treated for diabetes. WellPoint would also be able to see if that client got the necessary eye exams by an ophthalmologist, had kidney functions measured, got hemoglobin A1c tests and did other medical things needed to manage the disease.

"It will prevent the ravages of diabetes that good blood sugar control and good care can improve upon," said Nussbaum. "It will protect you, over time, from visual loss, from kidney deterioration."

And while a client's various doctors may not be aware of what the others are prescribing, advising or treating, the insurance company sees it all through the claims data.

"It's not as clinically deep, but they have it all," said Nussbaum of the insurance data.

The economic advantage for WellPoint is that prevention and management will reduce heavier costs down the road.

Don Maheu of Old Orchard Beach agreed. He's diabetic and was overweight. Through Anthem, he attended a workshop with a nurse who specializes in diabetes and nutritionist and initiated a new exercise program. His nurse case manager encouraged him and offered advice.

He's lost 90 pounds since February 2006.

"I've changed my lifestyle completely, and my doctor is happy with what's going on," said Maheu.

Maheu said the contact Anthem establishes and maintains with its clients can only help the company.

"If we take care of ourselves, they don't have to pay out so many medical expenses," said Maheu. "It's well worth it."

Nussbaum said he's heard criticism of the plan based on the chance that clients will switch plans, moving those long-term cost savings to a competitor, said Nussbaum. But that wasn't a concern for WellPoint, he suggested.

"We have deep market shares, we have strong persistency of our members," said Nussbaum. "The investment we make will pay dividends down the road for us. Even if someone were to go to peer health plan, our service will bring them back over the years."

Staff Writer Matt Wickenheiser can be contacted at 791-6316 or at: mwickenheiser@pressherald.com