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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.”

Insourcing

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.