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Physicians 1, DM 0

Les Masterson, for HealthLeaders Media, August 20, 2008

Seven months after the Centers for Medicare and Medicaid Services spiked the disease management-inspired Medicare Health Support (MHS) program, CMS announced last Thursday that a physician-run demonstration improved quality of care and saved money in the areas of congestive heart failure, coronary artery disease, and diabetes mellitus.

The 10 physician groups taking part in the Physician Group Practice (PGP) demonstration project earned $16.7 million in incentive payments and four of the groups earned an additional $13.8 million in performance payments.

Five of the physician groups also achieved benchmark quality performance on all 27 quality measures, and 10 of the groups achieved benchmark or target performance on at least 25 out of 27 quality markers.

"This CMS PGP demo project is a great example of large integrated delivery systems producing high quality of care while lowering costs," said James Lee, MD, who is spearheading the PGP project at Everett (WA) Clinic, during an American Medical Group Association teleconference last Thursday. "It is a great model for future American healthcare." If PGP is the future, does that mean DM and the Medicare Health Support (MHS) project are the past? By its actions this year, it seems CMS thinks so. "We are paying for better outcomes and we are getting higher quality and more value for the Medicare dollars," said Kerry Weems, acting administrator of CMS, in a prepared statement. "And these results show that by working in collaboration with the physician groups on new and innovative ways to reimburse for high quality care, we are on the right track to find a better way to pay physicians."

CMS' announcement about PGP is in stark contrast to the organization's thoughts about the DM-inspired MHS project. Some of the biggest names in the DM world joined MHS to test the model in a sickly Medicare population.

CMS is ending MHS this year, citing disappointing results. DM advocates are displeased with the project's demise, how the end was announced—a FAQ file on CMS' Web site and no press release—and lack of specifics as to the program's failings and lessons learned.

I recently spoke to a CMS official about the MHS project and the person said the demonstration is just the latest DM project to fail in the Medicare population. The official said CMS is ending MHS because it did not see "significant impact on utilization of services and therefore on costs."

The fact that physician-led projects in the PGP are showing savings and higher quality while the DM project is being shelved shouldn't come as a surprise. Patients feel a greater connection and have more respect for their doctors than a faceless nurse on a phone.

But don't write DM's obituary just yet. There is still a place for DM and health management in healthcare. It's probably not in the remote nurse call center though. The PGP project, which is the first pay-for-performance initiative for physicians under the Medicare program, shows the importance of involving physicians in care. Many DM companies have avoided physician interaction and dealt strictly with the patient. This has created confused patients and miffed doctors.

There has been movement in the past year to change that model. More DM companies see the importance of having the face-to-face advocacy of a physician in the care process. There has been an added focus away from the call center program that reaches out to the chronically ill to health management and wellness programs that connect with everyone. In fact, DM's major industry organization, the Disease Management Association of America, even changed its name last September to DMAA: The Care Continuum Alliance because of the industry's changed focus.

The demise of the MHS project was bad news for DM, but innovative leaders have already moved beyond the nurse call center model of DM to one that includes physician offices.

Care coordination is the present and future, and the DM companies that lead the way will be the ones that flourish.


Les Masterson is senior editor of Health Plan Insider. He can be reached at lmasterson@healthleadersmedia.com .
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