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The MCOs are internalizing this health management function for one reason, profit. None of the outsourced DM functions have been able to prove meaningful ROI, so why outsource? Pretend having a valuable service, collect extra permium (fees/ASO) and keep the cash.

How many members does WellPoint provice health care nationally? Their web site mentions 35 million. Assume 2/3rds, 1,000 of the 1,500 health management staff have clinical job functions and reach out to the 35 million members. This equals one nurse calling 35,000 members. UHC reports one to 45,000, Aetna one to 20,000 and CIGNA fails to understand/respond to the question.

MCO insourced/outsourced medical management is “vapor”. Employers and their consultants are failing their fiduciary responsibilities.

I began my career in healthcare with Blue Cross/Blue Shield in MIchigan, and did not find it any more obsessed with profit and prone to cheating than any other organization I know of, and probably a little less so, as a not-for-profit organization. And since Wellpoint and all other insurance plans engaged in EHM have to compete with specialized vendors, other plans, even health care organizations increasingly involved therein, the market will tend to keep the profitable cheating from getting outrageous. I personally know of no data on how many nurse coaches Wellpoint or other plans have engaged per participant in their EHM efforts, but since they have to show results, I imagine they are using other less labor-intensive methods, as well, since these have proven to be competitively effective/efficient, so the figures you come up with may not be truly reflective of how they go about their EHM efforts. Besides, with the average participation rates in most populations in the single-digit or low double-digit range, the ratio would have to be adjusted for that. The biggest challenge in EHM is to achieve an appropriate matching of the investment for each population, segment, and individual to the risk/reward prediction for each, so that it can yield adequate returns for client employers, EHM providers, and EHM participants alike. So far, the issue has seemed to be more the failure of many providers to deliver on their promises, particularly those unfortunate enough to choose CMS/Medicare as their clients, than their outrageous profits.

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