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Industry responds to RAND report

RAND Corporation’s report that there has not been enough third-party research showing that DM saves money was not a surprise to industry leaders.

For the most part, industry leaders do not reject RAND’s premise in “Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?” which was published in the December 2007 American Journal of Managed Care. Instead, they say there are reasons DM programs have not been widely reviewed: DM companies’ desire to maintain commercial secrets, the industry’s focus on improving—rather than reviewing—programs, and the simple fact that purchasers see firsthand the effect of DM and don’t demand independent research.

Soeren Mattke, MD, DSc, the study’s lead author, says RAND undertook the review because the think tank is reviewing presidential policy proposals to see which ones are supported by evidence. Mattke says presidential candidates can include DM programs in their proposals but warns they should not expect savings that could fund other programs, such as universal healthcare. Doing so is merely a leap of faith, he says.

“It’s very plausible that disease management would save money because we do know for a fact that chronic care is bad,” says Mattke, who coauthored the study with Michael Seid, PhD, and Sai Ma, PhD. “People with chronic conditions don’t get the tests they need, they don’t get the drugs they need, they don’t get the advice and education they need, and we do know that bad management of chronic conditions results in adverse long-term outcomes and also in high-cost events that could be avoidable.”

The belief that DM reduces hospital admissions and ER visits is plausible, Mattke says, but the industry simply hasn’t opened itself up to enough analysis to confirm that. “I’m showing that it hasn’t been sufficiently researched as to whether or not it does save money.”

Mattke says a literature search for studies on population-based DM programs found a total of three large-scale program evaluations. In those studies, researchers found “consistent evidence that disease management improves processes of care and disease control, but no conclusive support for its effect on health outcomes,” according to the report. Mattke says he is puzzled by how little independent research is available. He adds commercial disease managers have large databases that can spotlight the experiences of hundreds of thousands of patients before and after they enrolled in DM.

If the DM industry opened itself up for independent program review, Mattke says there would be greater buy-in to its chronic disease programs. However, until that kind of third-party research is completed, Mattke says payers and policymakers “should remain skeptical” and demand evidence that DM saves money.

DMAA: The Care Continuum Alliance responded to the RAND report by writing that DM is a “wise investment” even though there haven’t been many large-scale studies. Gordon K. Norman, MD, chair-elect of DMAA, wrote, “There are sound reasons why DM outcomes satisfy buyers today, even if academics remain unconvinced. Taking all the data and circumstances as a whole, it is reasonable and responsible to conclude that we are wise to continue investments in DM, while accumulating more and better evidence about the total population efforts.”

Disease Management Advisor spoke to a number of DM leaders in the aftermath of RAND’s release, and most acknowledged the report’s findings were expected—and there is nothing wrong with the conclusion.

“If there is no evidence that it does save money, there is no evidence to prove it doesn’t save money. The existing science can’t disprove that negative,” says Jaan Sidorov, MD, MHSA, FACP, an independent consultant and former medical director at Geisinger Health Plan in Danville, PA.

Sidorov adds just because there is a lack of peer reviewed medical studies doesn’t mean DM is ineffective. He likened independent evaluations to merely one window into the DM industry. Other “windows” have provided a different view and conclusion, he adds.

Christobel Selecky, CEO of LifeMasters Supported SelfCare, Inc., in Irvine, CA, doesn’t think the lack of double-blinded randomized control studies of DM is a problem. “At this point, I would say that the jury may still be out on what specifically works and what doesn’t in DM, and I don’t see anything wrong with that,” she says. “We are still in a rapidly evolving field, and it would be difficult to pick a point in time to say ‘this is DM’ and decide whether ‘it’ works or not since we are still doing lots of research and development to improve our processes and programs.”

Al Lewis, JD, executive director of Disease Management Purchasing Consortium International, Inc., in Wellesley, MA, says he was impressed with the study and agrees with RAND’s findings—except he’s a little more optimistic. Lewis doesn’t agree with either side of the argument—whether it is from benefit consultants, who promote huge savings via DM, or from academia, which is more pessimistic.

In regard to the movement within DM to review productivity costs rather than—or in addition to—direct medical costs, Mattke says that too has not been “sufficiently researched” by independent analysts.

Selecky says there hasn’t been a plethora of independent scientific research conducted by DM organizations because the industry is focused on continually improving its programs and finding ways to more effectively engage patients. Also, purchasers are not demanding proof from studies conducted by academic and scientific institutions because they understand that DM is having its intended effect on their own population.

Warren Todd, founder and past president and executive director of DMAA: The Care Continuum and founder and executive director at International Disease Management Alliance in Flemington, NJ, gave another reason why DM has not opened itself up to independent review: The industry is commercially driven, and DM companies therefore find it difficult to share proprietary information on what works and does not work.

There is also this argument: Should DM still even have to prove ROI? Lewis says DM has been around long enough that it is part of the healthcare landscape, and once an industry is part of the landscape, big returns are no longer demanded. For instance, no one would require an ROI on neonatal intensive care. DM may not save money, but it is a way to handle chronic diseases. “It’s quite possible to be optimistic about the future of disease management while at the same time to be realistic about the savings potential,” says Lewis, who is scheduled to discuss the RAND study further with Mattke and Ariel Linden, president of Hillsboro, OR–based Linden Consulting Group, during a session at the Disease Management Colloquium in May.

Although some have lamented RAND’s results, Todd says he is pleased that independent organizations are beginning to review DM and hopes other respected researchers will follow the RAND effort to bring more objectivity to DM program assessment. As well, the RAND report may be a wake-up call. “While the RAND results were somewhat discouraging, we may need some bad news like this to motivate the industry to recognize that investment in new models of disease management is needed,” says Todd.

RAND breaks down impact by diseases

As part of the “Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?” study, RAND Corporation researchers analyzed data on DM’s impact on six chronic condition areas: CHF, CAD, diabetes, asthma, depression, and chronic obstructive pulmonary disease (COPD).

Researchers noted they found evidence that DM programs improved the quality of healthcare in all areas except asthma and COPD. Those two chronic disease states showed inconclusive results.

The researchers also found:

DM reduced hospitalization rates for patients with CHF

DM meant higher utilization of outpatient care and prescription drugs for depressed patients

On the issue of depression, Soeren Mattke, MD, DSc, the study’s lead author, says patients with depression are commonly undertreated and an effective DM program in fact increases healthcare utilization and prescription costs. The authors, however, note there is little evidence that depression DM programs actually improve health outcomes over the long term.

Christobel Selecky, CEO of LifeMasters Supported SelfCare, Inc., in Irvine, CA, says that at a minimum, DM should be expected to improve quality without adding costs, but that generating cost savings is highly dependent on which chronic conditions and populations are being targeted and managed.

Mattke says the study shows the industry should open itself up for independent review. If that kind of review is done, then everyone would know what programs save money, which programs work better, and how DM can better tailor programs. After several independent studies have been published, the industry could conclude that there are simply some conditions in which it can’t save money, but that DM is still a valuable way to improve care.

“These data need to be out in the open so purchasers can make an informed decision rather than having to decide on vendor-based reports that are never validated by an outside entity,” says Mattke.