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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Disease Management in Vermont
Claim that DM saves money is an example of faith-based health policy
Disease Management: Like All Health Delivery Evolutionary Change, Disease Management Represents Neither Panacea Nor False Hope, But Real Progress
Alignment of Disease Management, Chronic Care Model
Support patients, not administrators
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Deborah A. Richter, Montpelier, VT Physician
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For seven years Vermont has had practical experience with disease management. Our two largest commercial insurers, which command 80% of the market, hire disease management companies. The experience has not been a happy one. First of all, these programs have had no discernible effect on Vermont’s health care costs. In the seven years costs have steadily, and steeply, risen from $2.2 billion to $4 billion this year. Secondly, they have exasperated primary care physicians who take most of the brunt of these programs. The majority of these physicians are dismayed at the intrusions in patient care by these outside disease management companies. These intrusions include bypassing physicians with calls placed directly to patients, often with erroneous diagnosis garnered from claims data. These outside programs are widely dismissed as time-consuming and useless. On the other hand it is believed that many physicians would welcome internally integrated disease management help, but they cannot afford it. Here in Vermont health care politics have trumped good health care policy. Our Legislature and Governor bought into the hype surrounding disease management as the newest hope in containing health care costs, despite widespread evidence to the contrary. The intention is to apply it to our Medicaid program. Dr. Geyman’s fine paper is the kind of evidence – there are others – that ought to have been mulled over before leaping to political conclusions. Competing interests: None declared |
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Kip Sullivan, Minneapolis, MN Writer, consultant
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Virtually all American health policy analysts now advocate evidence- based medicine. But many analysts do not practice evidence-based health policy. The gap between what many experts say about disease management (DM) and what the evidence says about DM is a case in point. As John Geyman has demonstrated in this paper, the literature on DM does not support the claim that DM saves money. Yet health policy experts who endorse evidence-based medicine are quite willing to promote DM as a money -saver. Consider these statements by James E. Pope and two other employees of Healthways, a DM company, in a paper with “disease management” in the title. The authors define DM to mean, among other things, “reinforcing evidence-based medical care.”(1) Then they say:"[Healthway’s] programs … lower costs by bridging gaps in care and helping participants better adhere to their physicians’ plan of care and evidence-based standards of care pertinent to their diseases. This approach leads to improved health … resulting in less demand on the system and lower cost."(2) In short, Pope et al. state that they believe in evidence-based decision-making by physicians, but they do not apply the analogous standard to themselves. Not surprisingly, the willingness of health policy experts to claim DM lowers costs has led numerous politicians, including several current presidential candidates, to make the same claim. As the faith-based rhetoric about DM's cost-cutting abilities becomes more intense, so too does the need for periodic literature reviews like Dr. Geyman’s. My only criticism of Dr. Geyman’s paper is that it is insufficiently pessimistic. Perhaps the most fundamental reason to doubt that the insurance and DM industries will ever provide effective DM services to substantial numbers of enrollees is that the average enrollee leaves his or her insurer every three years at most.(3)(4) This high turnover rate means that the insurers that offer truly effective DM services, or any other preventive service for that matter, will not reap returns on their investment that take more that a few years to materialize. This fact means that DM services will either be very inexpensive and, therefore, rather ineffective, or quite expensive but applied to only a small fraction of enrollees. If DM is incapable of cutting costs, either because the methods used have little effect on enrollee health or because the methods do improve health but not by enough to offset the costs of the DM services, inquiring minds want to know why the DM industry is now so financially successful. The answer is identical to the explanation for the financial success of managed care insurance in the 1990s. Managed care, like DM, had no conclusive empirical evidence to support the claims being made for it, but that did not prevent a huge market shift away from traditional insurance to managed care insurance as employers across the country cajoled or forced their employees into managed care plans. If managed care couldn’t perform as advertised, why did every insurer adopt managed care tactics? Answer: Because the non-evidence-based claims made for managed care by representatives of the insurance industry, big business, academia, politics and the media persuaded employers they should switch from insurers that did not use managed care to those who did. The absence of empirical evidence was irrelevant. The same explanation applies to DM in this decade. Policy makers responsible for government health insurance programs, and employers, are being persuaded by a barrage of advertising and faith-based assertions, not empirical evidence, that DM saves money. (1) Pope JE, Hudson LR, and Orr PM. Case study of American Healthways’ diabetes disease management program. Health Care Financ Rev. 2005;27(1):47-58, 48. (2) Ibid, 49. (3) Davis K, Collins KS, Schoen C, and Morris C. Choice matters: Enrollees’ views of their health plans. Health Aff. 1995;14(2):99-112. (4) Carrasquillo O, Himmelstein DU, Woolhandler S., Bor DH. Can Medicaid managed care provide continuity of care to new Medicaid enrollees? An analysis of tenure on Medicaid. Am J Public Health. 1998:88:464-466. Competing interests: None declared |
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Gordon Norman, Irvine, CA, USA Chief Science Officer, Alere Medical, Inc.
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Dr. Geyman, an acknowledged pioneer and Family Medicine leader, has attempted to summarize the current landscape for disease management (DM) programs and in so doing, has done Annals readers a disservice by excessively polarizing two alternative models for improved coordination of care and self-care management for patients with chronic conditions, both of which are currently providing not only hope but demonstrably improved outcomes of care for large populations of patients. It makes about as much sense for family physicians to dismiss the opportunity to work with companies who have specialized in delivery of DM services as it would for these physicians to refuse to refer to specialists or utilize external laboratories or imaging facilities when they reach the limits of their expertise or capabilities. Coordinating the care of their patients by working with other teams of educators, coaches, nurses, dieticians, and other DM staff external to their practices is not only desirable, but in most cases a necessity, given limited infrastructure for providing these DM services internally. The alternative is to deprive patients of the potential benefits of these programs altogether, a rather Draconian choice and one lacking informed patient consent. Speaking as a family physician and DM executive with a life-long quality improvement passion, I would readily agree that the ultimate structural and operational models for optimal long-term DM outcomes may not yet have been conceived or developed. That said, there are numerous viable models today – including the Chronic Care Model (CCM) and those of leading DM firms – for supporting patients with chronic conditions that are producing consistently positive results for many thousands of patients and their sponsoring employers and/or health plans. Despite the paucity of compelling evidence of DM financial and on- financial outcomes in the peer-reviewed literature, could it be the case that nearly all major health plans and myriad Fortune 500 employers are purchasing and supporting DM services out of some mass delusion of tangible benefits? Could the DM industry’s estimated compound annual growth rate of 40% from 1997-2004[i] be possible without purchaser decision-makers believing in the financial and non-financial returns from the various DM programs they are implementing? These entities are not known for CFOs who spend significant sums without serious consideration of ROI. So why is the published evidence on DM outcomes ambiguous? Not because DM is too new, since in one guise or another, these types of support programs have been around for 15 years, albeit in rapid evolution; rather, since commercial DM arose as an industry response to a business imperative rather than an academic one, it’s not surprising that few of the programs have been subjected to the rigor of randomized controlled trials. In the business world, RCTs are burdensome and costly to support, and many business purchasing decisions are based on far less evidence than already exists for the benefits of DM programs. Dr. Geyman asserts that commercial DM programs are not integrated with primary care, in contrast to CCM programs which are. My experience from a decade in the DM trenches is that the majority of DM companies make vigorous efforts to coordinate their activities with treating clinicians, who they acknowledge retain the primary caregiver role on the expanded care team. In my own company’s case, this includes faxed alert reports to attending physicians whenever patients trigger pre-established, clinician- approved, biometric and/or symptom parameters, or manifest some other important need for physician intervention, such as medication non- adherence, etc. We can’t do this job alone, nor would we want to; it is vital that we collaborate with treating clinicians in order to be as successful as possible. (May I respectfully suggest the converse may also be true?) Speaking as a Board member of DMAA, neither that organization nor its member organizations would propose that disease management is best done by avoiding integration with the delivery system. Quite the contrary; in fact, many DM companies are fully-enabled with EHRs that are ready to mate with provider EMRs as soon as they are more widely adopted throughout the delivery system. DM programs today perform a variety of services that are not easily supported by most provider practice infrastructures. These include the remote monitoring of biometric and symptom parameters for daily analysis and intervention when needed, the monitoring of PBM pharmacy claims to determine gaps in evidence-based care and adherence to prescribed medications, and coaching of patients at “teachable moments” when their readiness to change is heightened and significant behavior change is most likely. Dr. Geyman points out that “optimal management of chronic conditions is complex” and asserts “it is best done by well-trained primary care physicians working closely with other health professionals on a team basis.” I wholeheartedly agree, and believe that DM firms seek the same goal. We wish to be a member of that team, not run the team. We view our services as complements to primary care, not as substitutes; we provide eyes and ears for treating clinicians for all the times their patients are not in the office, through remote electronic and telemonitoring services. And we supplement and reinforce the education and motivation that physicians are challenged to provide these patients in today’s pressured office visits. Even the most devout traditionalist physician would not advocate that primary care should be delivered out of a black leather bag through house calls, as per the mode of 50 years ago. Likewise, in 21st century health care, comprehensive and continuous care should no longer be defined as only what takes place in the confines of a clinician’s exam room. Even for patients visiting their physicians on a monthly basis, this face-time represents less than 1% of these patients’ waking hours over the course of a year. Surely some form of ongoing monitoring, education, support, encouragement, congratulations, and tracking is appropriate for the other 99% of their lives in a manner conducive to more efficient and effective care, to improved clinical and financial outcomes, to healthier patients and happier physicians? Dr. Joe Scherger, another Family Medicine visionary and Professor in the Dept. of Family and Preventive Medicine at University of California, San Diego, noted in his 2005 talk, The End of the Beginning: The Redesign Imperative in Family Medicine[ii], “So what is wrong? Not what we do, but how we do it; our process of care is ineffective and obsolete. The brief visit model is an acute care model, but we now do preventative care, chronic illness management, biopsychosocial and family systems oriented care. Family Medicine’s care model no longer fits the work we do.” Dr. Scherger understands that a new paradigm for care of patients with chronic illness is overdue, and believes that technology-enabled e-Health is a resource that must be deployed to achieve a better fit. As observed by Dr. Larry Green, Dept. of Family Medicine, University of Colorado[iii], “Family practice has spent too much effort justifying its existence and too little on securing the practical means to accomplish its goals of comprehensive, continuous, coordinated care.” He goes on to say, “Relatively little effort has gone into designing optimal settings in which the best tools can be marshaled to sustain relationships and to execute reliably the services that are needed, based on their importance. Implementing systems that capitalize on new technology has been slow…” I submit that disease management principles and programs, whether implemented by multispecialty provider groups or outsourced to professional disease management firms, are one appropriate means to help close the gap between the promise and the reality of Family Medicine. Dr. Green further notes, “Because many of its boundaries remain indefinite and contested, family practice and other medical specialties and professional groups are often positioned to invade and dispute each others ‘territory,’ compete rather than integrate, and defend rather than engage. Meanwhile, the balanced cooperation critical for the superior performance people deserve from the health care system may not occur.” Primary care and DM must avoid getting caught in turf wars. Primary care performs a breadth and depth of care delivery roles well beyond those targeted by DM, and DM provides capabilities and services that are complementary to primary care in one of its most challenging areas, the care of patients with chronic illness. “Balanced cooperation” should be the order of the day between primary care and DM. Meeting patients with chronic conditions in their own environments, on their own terms, via their own preferred communication media, and within their own lifestyles and on their own timetables is partly what will differentiate the patient-centric approach to health care from prior models. Most DM programs have already taken this approach to engaging and communicating with patients. The Future of Family Medicine Report[iv] notes, “To achieve top performance, family physicians must practice on a daily basis scientific, evidence-based, patient-centered care; they must accept a measure of responsibility for the appropriate and wise use of resources; and they must work in teams within and beyond their practice setting, focusing on the integration of care for each of their patients.” DM already shares many of the report’s suggested attributes for the New Model of family practice: patient-centered care, whole-person orientation, a team approach, elimination of barriers to access, advanced information systems, and a focus on quality. Dr. Green concludes, “Family practice’s future may depend fundamentally on its ability to commit to intellectual development, integration into a revised health care system, and an abandonment of the role of victim.” There is no basis for clinicians to feel they are or will be victimized by disease management. Those who are able and desire to internalize the tenets of DM via the CCM are encouraged to do so; for the thousands of solo and small group practices that are unprepared to do so, many qualified and experienced DM firms exist with whom they and their payors and employers can work to address the unmet needs of the chronically ill. There is more than enough chronic disease to fully occupy us all. Looking back at the arc of Family Medicine 3 decades after its founding as the 30th medical specialty, another of its founding fathers, Dr. G. Gayle Stephens, lamented in retrospect[v], “We’ve had to settle for less than we had hoped for. We hoped for everyone to have access to a personal physician—we’ve discovered that not everyone wants or can utilize a personal physician properly. We hoped to produce compassionate physicians—we’ve had to settle for producing less cynical ones. We hoped to teach continuity care but found that there was little time in which to do it. We wanted to educate the patients but found that we ourselves lacked the education to do it. We wanted to integrate the art and the science but seemed always to have to choose one or the other. Perhaps our unfulfilled hopes are less remarkable than that we hoped at all.” DM can assist with patients with highly fragmented care, can improve their continuity of care, can provide additional education resources, and thereby provides not only hope but tangible support for the original vision of Family Medicine – to provide continuing and comprehensive medical care, health maintenance, and preventive services to each member of the family regardless of sex, age or type of problem, be it biological, behavioral, or social. Extremism is neither useful nor appropriate in characterizing DM as either Panacea or False Hope; it is neither, whether implemented in the Chronic Care Model or by a commercial DM company. What it can offer to patients with chronic conditions, their families, and their physicians is a set of tools and resources to improve self-care and adherence to treatment plans. The best of these programs can extend patient longevity, reduce morbidity, improve quality of life and functional status, and often with reduced health expenditures. True, not a panacea, yet no small feat. Given the growth and success of disease management for a wide variety of patients and sponsors – including most health plans, Medicare, Medicaid, Veterans Administration, and many employers – it seems highly unlikely that “outsourced DM programs will end up as just one more policy failure, undermining primary care and delaying increasingly urgent health reform,” as predicted by Dr. Geyman. DM can and should fortify primary care with expanded capabilities for caring for chronically-ill populations. Other fundamental reforms are clearly needed for a fragmented health care delivery system that leaves 47 million uninsured and produces poor value as measured by multiple outcomes for the invested 17% of GDP that we now spend on healthcare. But I believe DM – regardless of whatever future labels replace this already obsolete term, and whether these programs are rendered on an insourced or outsourced basis by health plans or provider organizations – is here to stay and will continue to be a key component of 21st century health care delivery. For the sake of our patients (and our aging selves), I certainly hope so. --------------------------------------------------------------------- ----------- [i] Boston Consulting Group, Realizing the Promise of Disease Management, February, 2006 [ii] Joseph E. Scherger, MD, MPH, The End of the Beginning, Blanchard Memorial Lecture, May 2, 2005 [iii] Larry A. Green, MD, George E. Fryer, MD, Family Practice in the United States: Position and Prospects, Academic Medicine, Vol 77, No.8, August 2002 [iv] The Future of Family Medicine: A Collaborative Project of the Family Medicine Community, Ann Fam Med, Vol.2, Supp.1, March/April 2004 [v] G. Gayle Stephens, MD, Family Medicine as Counterculture, Fam Med 1998;30(9):629-36 Competing interests: None declared |
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William C. Popik, MD, FAAFP, South San Francisco, CA Chair, Disease Management Association of America; SVP & CMO, LifeMasters Supported SelfCare, Paul Wallace, MD, and Gordon K. Norman, MD
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We share Dr. Geyman's passion for improving the care and health outcomes of people with chronic medical conditions. Like him, we recognize the importance of primary care physicians and the Chronic Care Model as key elements of care for these deserving populations. We question, however, the value of his focus on sustaining polarized views of the Chronic Care Model and disease management. Instead, we see the evolving principles and practices of care in both integrated systems, such as Kaiser Permanente, and disease management as aligned with the Chronic Care Model's core concepts and increasingly convergent in their approaches to optimal and widely accessible chronic condition care. As Dr. Geyman notes, the needs of the chronically ill increasingly dominate the overall business and clinical basis of health care today. Creating adequate capacity and access—both current and future—as these patients also go about their daily lives requires creative leveraging of existing assets and aggressive development of complementary capabilities. Examples include predictive modeling and health coaching to support and sustain patient behavior change. We see an essential and continuous leadership role for the primary care physician. But we also fear for both physician and patient if the expectation is that the physician acting alone must develop all the necessary systems and skills for continuously improving care for these individuals. The experience of both integrated systems and disease management companies is that optimal chronic condition care is very much a "team sport" with important but different roles for clinicians, associated team members, support systems (including information technologies) and, most critically, patients. We strongly recommend that future discussions focus on recognizing where each approach has identified successes and barriers. Primary care physicians lack the time, resources and, often, training to do it all. Supportive systems of care, such as provided by disease management companies, must align with and support the patient-clinician relationship. We see examples of this evolving alignment almost daily. Kaiser Permanente, for example, has created a free-standing disease management company, Avivia, which counts both non-Kaiser integrated systems of care and commercial employers among its customers. As we refine our clinical understanding of people with chronic conditions—especially those challenging individuals with multiple co-morbid conditions—it will take all the capacity and expertise we can collectively muster to fulfill a common core goal of addressing the diverse needs of the patient. This ultimately defines both good care and good business. William C. Popik, MD, FAAFP Paul Wallace, MD Gordon K. Norman, MD Competing interests: None declared |
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Don R. McCanne, M.D., San Juan Capistrano, CA Senior Health Policy Fellow, Physicians for a National Health Program
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This article could not be timelier. In response to growing concerns about the affordability of health care, the political arena is awash with proposals to control health care spending. Unfortunately, because of the timidity of the politicians in confronting the powerful vested interests that are wasting so much of our resources, they are turning to pseudo-solutions such as the commercial variety of disease management. The private health insurance industry has been aggressive in its marketing of innovative products that shift risk from insurers to taxpayers and to patients with greater health care needs. While abandoning the risk pooling function, they have been selling us more and more administrative services. The commercial disease management programs compound this administrative waste, while introducing yet another disruptive, intrusive element into the clinical arena. Yet the deficiencies in chronic disease management are very real. But rather than wasting more resources on third party managers, the solution is to reinforce our rapidly deteriorating primary care infrastructure. A strong primary care base provides the ideal environment in which to develop an effective chronic disease model. Barbara Starfield and others have demonstrated that this would not only improve quality of care, but would also address the issue of affordability by ensuring more cost-effective care. To accomplish this, incentives need to be realigned to encourage the improvement and expansion of the primary care infrastructure. This would be a simple task for the public administrators of a single national health insurance program. Crafting reform that leaves the private insurance industry in play would only direct more resources to their primary product: ever more wasteful administrative services. We need to take care of our patients, not our insurers. Competing interests: None declared |
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