Disease Management Advisor, January 2008
Looking into the DM crystal ball
Blue Cross/Blue Shield promotes medical home demonstrations
What's next for Medicare?
Pharmacy program with DM component targets CKD
Program brings hypertensive patients within BP ranges
Disease Management Advisor 2007 Index
Looking into the DM crystal ball
Greater integration expected in 2008
Editor's note: Disease Management Advisor asked DM leaders to predict what will happen in the field this year. In this issue, we have compiled articles highlighting their predictions.
A coalescing of DM, prevention, and wellness under a larger umbrella of chronic care management is a trend many in the DM field are predicting for 2008.
Ariel Linden, DrPH, MS, of Linden Consulting Group in Hillsboro, OR, points to wellness as the "hottest topic" in DM and estimates that it has grown tremendously in the past couple of years.
"It's now the new frontier," says Linden. "It's funny because it's not a new topic. Health promotion has been around since the '40s . . . But suddenly, everyone has recognized that wellness is important and there are long-term savings to be had. So everyone is looking seriously at preventative measures, along with applying more evidence-based behavioral change strategies."
Linden expects that most health plans will offer wellness programs, and David B. Nash, MD, MBA, chair of the department of health policy at Jefferson Medical College of Thomas Jefferson University in Philadelphia, predicts those services will become the norm within the next year to 18 months.
Vince Kuraitis, JD, MBA, principal of Better Health Technologies in Boise, ID, is surprised wellness has become such a popular concept, namely because gauging ROI is more difficult and payback takes much longer for wellness programs. He says companies with long-term employees, such as automobile companies, understand the economic incentives in offering wellness programs. "I'm a little surprised but also pleased to see that wellness seems to be persisting in the marketplace," says Kuraitis.
Nash expects "very aggressive corporate health activities" that will penalize employees who don't comply with health improvements, such as smoking cessation and weight loss. He says some companies will offer free counseling or provide access to appropriate resources to help employees tackle specific health issues. If the lifestyle changes are not implemented after a given time, Nash foresees employers terminating noncompliant employees.
"Corporate America is fed up and recognizes that they have a real role," says Nash, adding that if workplaces have to offer health insurance, then those companies should lead how insurance is organized and deployed.
Jim Giuffre, MPH, president and chief operating officer of Healthwise in Boise, ID, says wellness is a trend toward investing in the whole population, not just those who are chronically ill.
There is a huge opportunity to save hospital costs by finding those who are in at-risk categories and engaging them in work-site wellness, DM, and online self-management programs. "I see both employers demanding it in their [request for proposals], and I see health plans and DM companies expanding their programs," says Giuffre.
Finding those at-risk folks will require "smart predictive modeling," says Julie Meek, DNS, chief science officer at CareGuide in Coral Springs, FL, and founder of The Haelan Group in Indianapolis. She predicts employers will switch to health assessment surveys that provide individual results to employees and allow confidential outreach and expert coaching assistance to those at risk for being high spenders.
State of DM
DM is an industry in flux; Meek says one needs to look only at Disease Management Association of America's recent name change to DMAA: The Care Continuum Alliance to see the evolving nature of the industry.
Meek says DM is entering the "dawn of a new era," and integration is a movement that has been in the making for three to four years. "I think what smart companies are doing is taking the essence of DM, which is that people have knowledge and skill gaps related to the management of their chronic care conditions, but understand now that people also have decisional, behavioral, and care coordination needs as well that need to be fully integrated."
Another change in the market is that several health plans have started to insource DM programs. Notwithstanding a potential shift from outsourcing to insourcing, Warren Todd, MBA, founder and executive director of International Disease Management Alliance in Flemington, NJ, says health plans have generally been slow to develop their own DM services because of four reasons: inertia, relationships built between the plans and DM companies, the ease of outsourcing the programs, and the fact that DM companies are doing a "very good job" managing client relations. Any change in insourcing versus outsourcing will likely depend on how successful DM companies are in reengineering existing programs in such a way that health plans are not able to duplicate them.
"I think health plans and DM companies will find themselves in a competitive situation. They are both doing 'medical management,' " says Todd, adding that smaller health plans will still need to rely on DM companies because they don't have the capacity to offer full-blown DM programs. One way for DM companies to prevent the shift to insourcing of DM by health plans, according to Todd, is to create programs that are so sophisticated that a health plan could not replicate those services. Todd expects DM's second- and third-generation programs to rely heavily on new technology, and he points to several recent instances in which technology and DM companies have joined forces.
Kuraitis says he is optimistic about growth in the DM market. DMAA: The Care Continuum Alliance conducted a market analysis that estimated the market potential at $30 billion in 2005. However, today the market is still under $2 billion, which Kuraitis says suggests there is room for growth.
"There's a tremendous amount of upside," he says. "If we see glitches or bumps in the marketplace, there is still a lot of chronic care that needs to be delivered."
Nash says the DM industry will need to make changes, particularly after the difficulties faced by CMS' Medicare Health Support project. "We are going to have to regroup and expand into work-site wellness, retail clinics, [and] corporate-based individual employee incentive programs. DM is going to have to evolve," says Nash.
The new DMA
Welcome to the new, expanded version of Disease Management Advisor. This month's issue may look the same from the cover, but inside, there's an added bonus.
Starting with this issue, DMA is including Medicare Disease Management as a monthly supplement to each issue of DMA. We are merging MDM and DMA to bring even more information to the loyal subscribers of these two publications.
Subscribers of MDM will continue to receive the same valuable information about Medicare DM programs, but with the added benefit of receiving DMA.
For those new to DMA, this publication provides real-world examples and practical strategies to help make your DM programs a success.
In other words, with the new DMA, readers are getting the best of both worlds.
You are not only learning about successful programs and strategies in the general DM realm, but you're finding out which Medicare DM programs have been successful and which have struggled-and how you can learn from those successes and failures.
This is an exciting time for us, and we hope the improved publication will benefit you and your business. Thank you for your continued support.
ROI dispute continues
How to properly and accurately evaluate ROI has long been debated in DM. DMAA: The Care Continuum Alliance has tried to resolve the issue with the second volume of the Outcomes Guideline Report, released in September 2007, by adding new clinical measurement statements. The report came in response to requests from providers and other stakeholders concerned that DM needed to create consistent and proper outcomes guidelines.
Several DM experts point to DMAA's Outcomes Guideline Report as proof that the industry is serious about creating more rigorous ROI guideline measurements, especially given Medicare demonstration projects.
"I think the industry has learned that this is an extremely complex process," says Vince Kuraitis, JD, MBA, principal of Better Health Technologies in Boise, ID. "I commend what DMAA has done the last two years to get its arms around ROI and the common methodological issues across companies. I think those have been constructive efforts and begin to provide some consistency, though [they] don't fully address the problem."
Julie Meek, DNS, chief science officer at CareGuide in Coral Springs, FL, and founder of The Haelan Group in Indianapolis, serves on DMAA's Outcomes Steering Committee, which worked on the Outcomes Guideline Report. She says the industry has made "enormous strides in publishing evaluation guidelines."
The heart of the struggle, she says, is that the DM industry is faced with several types of entities that are not conducting proper ROI analysis or using correct methodologies.
Clients don't know how to recognize bad outcomes data, so they hire actuarial, benefit, or brokerage houses, which often use incorrect methodologies or simply don't know the nuances of conducting complicated outcomes analyses, Meek says. "They tend to promulgate a methodology that is not necessarily as robust as it can be," she says.
Meek says DM has to raise awareness of the ROI issue among employers so they understand that many of their financial consultants are not working with proper methodology.
"Clients are laypeople who don't have PhDs in research like we do. Translating outcomes to clients, I think, is really something that needs a lot of the industry's attention and certainly will be something I advocate for within DMAA," says Meek. "It's headed in the right direction. It's not there yet."
Though a number of DM experts applaud DMAA's Outcomes Guideline Report, not everyone is satisfied. Ariel Linden, DrPH, MS, president of Linden Consulting Group in Hillsboro, OR, encourages the industry to move beyond the status quo of measuring financial outcomes using a pre-post method and applying an actuarial trend line.
"Given that the standard industry method always shows large program savings that cannot be replicated when strict research designs are used, we must push the industry to follow more rigorous, and defensible evaluation methods," he says.
David B. Nash, MD, MBA, chair of the department of health policy at Jefferson Medical College of Thomas Jefferson University in Philadelphia, says the industry needs to include other measures to calculate ROI.
The industry should measure programs' successes by evaluating presenteeism, absenteeism, and overall productivity in relation to DM program participation. "I believe that the ROI calculation is going to evolve, and so we need to move away from disease-based calculations to a productivity basis," Nash says.
Warren Todd, MBA, founder and executive director of International Disease Management Alliance in Flemington, NJ, says not having that kind of data to weigh the success or failure of programs has hampered DM's growth.
He hopes that the second and third generations of DM programs provide literature that properly measures programs.
Though most agree the industry is moving in the right direction when it comes to ROI, financial experts say there is still room for improvement.
"I expect we will be debating ROI in DM for quite a while," says Kuraitis.
Technology will play bigger role in 2008
Technology has changed the way Americans bank and shop, so it makes sense that healthcare would develop technology that targets chronic care. Technological advances in DM are making it possible for patients to telecommunicate with their doctors and for physicians to collect health information and change care if warranted. David Whitlinger, president and chair of the board of Continua Health Alliance in Beaverton, OR, says technological improvements are a needed change in the healthcare system.
"The belief is that the healthcare system has to change. That individuals and families will have to become much more a part of the caregiver aspect of delivery of healthcare and, from that, these personal telehealth tools will be key," says Whitlinger, who is also the director of healthcare device standards and interoperability for Intel Corp. in Beaverton, OR.
David B. Nash, MD, MBA, chair of the department of health policy at Jefferson Medical College of Thomas Jefferson University in Philadelphia, says big players such as Google and General Electric are driving technological advancements in healthcare, and he expects wireless Internet-enabled technology that utilizes cell phones to become a larger part of the market.
"Technology is going to evolve so that the cell phone or its equivalent will be a medical, social, networking tool," says Nash.
Ariel Linden, DrPH, MS, president of Linden Consulting Group in Hillsboro, OR, says DM companies are now realizing the need to collect daily health data from patients at high risk of hospitalization. Emerging telehealth technology is more effective than the old DM model, he says.
"We need to move beyond the model of making outbound calls to patients every three months, talking to them for 15 minutes, and expecting that to keep them out of the hospital. We need to take advantage of advanced technology, plus incorporate interventions that are based on the best behavior change science," says Linden.
Whitlinger expects to see a large number of remote monitoring DM trials focusing on people with diabetes this year.
Whitlinger says he won't be surprised if those trials are successful, the programs double in size, and telehealth becomes the norm for patients and providers to monitor diabetes daily.
Although he expects growth in the diabetes market, Whitlinger predicts modest movement in technology for chronic disease patients who are homebound or nearly homebound. In addition to helping patients, the telehealth and online improvements will help caregivers, says Jim Giuffre, MPH, president and chief operating officer at Healthwise in Boise, ID. Many baby boomers don't live in the same region as their parents, but technology is allowing them to keep track of their loved ones.
"New Web-based technologies allow older people to enroll in online programs, including interactive conversations that give them helpful information for managing their conditions. Parents can share this information with their baby boomer sons and daughters, so they can really assist and reinforce their older parents in managing their health," says Giuffre.
Giuffre expects online social networking to play a larger role in people's search for health information. With that added networking, health companies will need to confirm the information is medically accurate. "The challenge there is knowing what is evidence-based and what's not," says Giuffre.
He also expects more federal demonstration projects involving technology and pay-for-performance-though probably not in 2008.
Gordon Norman, MD, MBA, executive vice president and chief science officer at Alere Medical, Inc., in Reno, NV, expects to see broader adoption and interoperability of technology, particularly in personal health records.
"Without interoperability and standard formats, there's not going to be much progress."
Continua leads technology charge
David Whitlinger has crisscrossed the country since the Continua Health Alliance effort was launched in June 2006, building bridges that have laid a foundation that Continua members hope will bring an interoperable telehealth system this year.
Whitlinger is president and chair of the board of Continua Health Alliance in Beaverton, OR, a collaboration of an ever-growing group of 135 companies working to establish a system that allows interoperable personal telehealth products that empower people and organizations to better manage health and wellness.
Whitlinger says creating interoperable telehealth systems is critical as the nation faces a doctor shortage coupled with an aging boomer population. "To a large degree, many in the health policy world believe that the healthcare system simply has to change because of scalability," says Whitlinger. "Because of the demand for healthcare and the insufficient number of beds, hospitals, and doctors . . . the scalability is going to hit us square in the face in a decade and a half."
Whitlinger says the idea of greater interoperability germinated in Intel Corporation's offices in Beaverton, where he is director of healthcare device standards and interoperability. Intel officials sought to take what they learned from other marketplaces and create a team of companies that would develop an interoperable system that would become the telehealth norm.
Whitlinger began reaching out via phone to gauge interest and forged ahead with face-to-face and summit meetings before Continua launched in June 2006.
Continua includes many of the big names in technology, including Dell, IBM, and Panasonic, and health insurers and DM companies, such as Aetna and Kaiser Permanente.
Whitlinger says Continua officials have spoken to CMS about telehealth reimbursements.
"[CMS is] running some of their own trials to see the effectiveness of remote monitoring . . . That's all building up in some sort of CMS policy in this regard," says Whitlinger.
Continua plans to have completed interoperability guidelines at the beginning of this year, which will allow companies to go through Continua's certification process and guarantee out-of-box interoperability. "It will probably be early , but we have already had some plug fests where companies had brought together prototype devices and tested those. Each quarter, we will include those events. By the time the guidelines are published, I expect several parallel products will be certified. The first half [of 2008] will be pretty exciting," says Whitlinger.
Continua has also signed up ADT Associates to collect remote patient monitoring studies published in the United States and Europe.
With that information, which may be released at the beginning of this year, Whitlinger says Continua will assess common barriers to adoption and then begin talks with payers in the middle of the year.
He expects remote monitoring services and electronic health records that share data across networks to be in Version 1 of the software interface. Whitlinger predicts a handful of those interfaces will be shipped in 2008, possibly in the third quarter.
Continua is a necessary step to address the lack of remote monitoring device interoperability, says Vince Kuraitis, JD, MBA, principal of Better Health Technologies in Boise, ID.
Kuraitis is bullish about the technology and says making devices plug and play will help, but he says there are at least two more fundamental issues: reimbursement and licensing. Interoperability will raise the "ugly head" of licensing across state lines and other legal regulatory issues.
"I think they will be more problematic once we get some of these other things out of the way," says Kuraitis, referring to the licensing issues.
Blue Cross/Blue Shield promotes medical home demonstrations
The concept of a medical home is taking shape in several demonstration projects that include elderly patients with multiple chronic conditions, as well as fewer sick patients who stand to gain from wellness and DM interventions that are led by the patient's physician. Some of the largest insurers in the country are leading the way in this effort. Blue Cross and Blue Shield Association (BCBS), Chicago, and 27 participating BCBS companies have joined with four major U.S. physician groups, national employers, and consumer groups to examine the medical home model of care in primary care demonstration projects around the country.
Many of these demonstrations are an outgrowth of existing efforts to focus on patients and give the lead to doctors. They were the main subject of discussion at a stakeholders' meeting in Washington, DC, in early November 2007 about the patient-centered medical home.
"Our providers came to us back in 2004 and said, 'Disease management belongs to doctors,' " says Jon Rice, MD, senior vice president and chief medical officer for BCBS of North Dakota in Fargo, who is organizing a demonstration in his state. "Our doctors said, 'Give us the seed money, and we will manage patients and demonstrate cost savings.' "
Rice says the demonstration is an extension of the initial program that his company started in response to the request from doctors.
"Our program began with a series of stakeholder meetings to help us understand how to better add value to services provided by our physicians," says Barbara Ann Muller, MD, medical director for Wellmark BCBS of Iowa. "We wanted to find a better way to support the doctor-patient relationship than the current broken and fragmented system."
The North Dakota model
BCBS of North Dakota covers more than 450,000 members in North Dakota and Minnesota. MeritCare, an integrated clinic and hospital system and the state's largest group practice provider, with more than 400 physicians, is the leader of this demonstration project. The doctors in this practice conducted an Advanced Medical Home Project beginning in 2005 that enrolled more than 3,000 members with only $20,000 in start-up money, says Rice.
Results for the enhanced diabetes DM services, including nurse education and an electronic medical record to monitor and manage patient needs, were measured using a control group.
The 2005 program resulted in savings of $500 PMPY, with the savings split equally between BCBS and the physician group.
Rice says the new demonstration program began September 2006 and has already enrolled 246 patients. He anticipates that approximately 2,000 members will be enrolled over the two-year course of the demonstration. Based on projected savings similar to the earlier demonstration program, BCBS is paying physicians $175 per enrollee up-front, says Rice.
"Because we already have an electronic health record, we can now focus on putting more people in place to help improve clinical outcomes," he says.
This includes a nurse educator and chronic care case management nurses. "We felt that we would achieve more improvements by giving the practice money at the start of the program rather than at the end," says Rice.
When the American College of Physicians first approached BCBS of North Dakota about participating in the patient-centered medical home demonstration project, the insurer wasn't sold on how it might achieve additional improvements, says Rice. "We were already vertically integrated with our hospital affiliation, and the electronic health record had made our operations much more centralized and patient-centered," he says. "We decided to focus this next improvement step on improving the relationship between doctors and patients by hiring a nurse who serves as a combination educator and patient facilitator."
BCBS of North Dakota may expand the program during the course of the demonstration if the outcomes are positive, he says, but the company would likely wait to make this determination until December, when it has at least one year of claims data to review.
Registry helps decrease fragmentation
Two years ago, Wellmark BCBS of Iowa in Des Moines brought together stakeholders for what Muller describes as "frank discussions about the future."
One of the key concerns raised at these meetings was that PCPs didn't know what was happening with their patients when they were seen by other doctors, she says.
"Coordination of services was lacking," says Muller. Physicians also realized that they were providing little to patients in the way of wellness and prevention. This wasn't a priority during brief office visits.
"From the patient's perspective, we heard about fears of harm when interacting with the healthcare system and their own doctors based on media reports and government reports," says Muller.
"There were any number of support services, but they were not being aligned for the sake of the patients, and physicians were not coordinating care for their patients because they lacked information," Muller adds.
Something had to be done. "After all, who knows the patient better than their own doctor?" she says.
"A true medical home has all of the patient's information, and that's the system that we want to achieve," says Muller. "What we started to do then and will continue in this demonstration is to go back to the drawing board and find ways to improve and prevent illness and disease complications," she says.
A major key is now in place-a patient registry that is tracking information from 1,200 clinicians. Office nurses now review each patient's overall care plan and any corresponding services that have or have not been provided when the patient comes for a visit.
"The nurses are highly trained to use decision support tools and assess the implementation of the care plan," says Muller.
For example, a DM nurse may see that a diabetes patient hasn't had a foot or eye exam or that a patient with congestive heart failure hasn't refilled a prescription drug. It also alerts the nurse and doctor to any potential medication interactions.
During the demonstration period, Wellmark is encouraging its participating physician groups to devise their own strategies for quality improvement and the implementation of a patient-centered medical home in their own practice setting, says Muller. "We don't want to be prescriptive," she adds. Each practice will choose an area to focus on. For example, one practice is implementing a diabetes DM program, while another is focusing on immunizations.
Wellmark will use the new standards for medical homes developed by the National Committee for Quality Assurance to measure the success of individual efforts.
As part of the demonstration, DM nurses will be on call for patients around the clock. Other new components available to practices are medication management and wellness prevention. "We want to give our physicians something tangible that can improve their practice," says Muller.
This particular demonstration will not have a practice management fee.
"As demonstrations gain momentum, we will be able to see what works best and make financial commitments in those areas," Muller says. The issue of pay-for-performance incentives for doctors is a growing dilemma. Should they be based on best practices, HEDIS measures, or actual patient outcomes? Do financial incentives actually affect physician practice behavior?
"Nobody really knows how to structure practice management payments or how to best reward physician practices," says Muller. "Our doctors haven't asked us for money. They want to improve their own practices and their patients' care."
National summit addresses benefits of patient-centered medical home
At a national summit held in Washington, DC, in early November 2007, several commercial providers-
as well as CMS-expressed support for what is now called the "patient-centered medical home."
The hallmarks of this concept stand in contrast to Medicare's premier DM program in the fee-for-service population, Medicare Health Support (MHS). The patient-centered medical home is led by the patient's physician, who coordinates care for all chronic conditions that a beneficiary may have, and is driven by the goals of achieving improved clinical outcomes and reduced healthcare costs.
CMS is finding that the MHS model lacks integration with physicians, involves more than one physician overseeing multiple chronic conditions, and is facing resistance from hospitals and other providers who do not want to see a decrease in reimbursements for care, according to Linda Magno, director of demonstration projects for CMS.
Magno spoke at the Patient-Centered Call to Action Summit, a meeting sponsored by the Patient Centered Primary Care Collaborative (PCPCC), a coalition representing business leaders, policymakers, and more than 300,000 PCPs. Political leaders, such as former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA) and Congressman Patrick Kennedy (D-RI), also were on hand to promote the medical home model.
Paul Grundy, MD, chair of the PCPCC, explains the new model this way: "The patient-centered medical home concept provides primary and preventive care that is personalized for each patient. It emphasizes the use of health information technology, including electronic health records, to help prevent and manage chronic disease and features consumer conveniences such as same-day scheduling and secure e-mail communications between the provider and patient." Participants in the collaborative include four professional groups representing physicians (American College of Physicians, American Academy of Family Physicians, American Academy of Pediatrics,
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