Three Takeaways from the MHS Project—So Far

The second interim report of the Medicare Health Support (MHS) project, released to Congress just before the new year, brings into better focus why CMS ended the disease management project last year.

Looking back at the first 18 months of the three-year MHS pilot, the report found that DM programs did not save money, improve beneficiary self-management, and physical and mental health functioning, or cut acute care utilization or mortality. None of the companies involved in the pilot reached the targets that would warrant program expansion as the programs did not improve clinical quality of care and beneficiary satisfaction, or achieve budget neutral spending targets, according to CMS.

Ouch.

MHS was created as the first test of DM in the Medicare fee-for-service (FFS) population, and as these interim results show, it was not a success. In fact, when I asked a CMS official what was learned from MHS, she said CMS did not find much that actually worked. Double ouch.

DM struggled in its first foray into the Medicare FFS population after growing into a more than $2 billion business in the commercial and Medicare Advantage populations, but DM leaders hope the industry can learn from the pilot.

The eight Medicare Health Support Organizations (MHSOs) used the call-center foundation of DM as the primary model in MHS, and supplemented different approaches, such as physician outreach and face-to-face interactions with beneficiaries. So far, through its two interim reports, CMS has not broken down the projects to highlight the MHSOs' different approaches and their affect on quality, self-management, and outcomes.

Gordon K. Norman, MD, MBA, executive vice president, science and innovation, at Alere, a DM company in Reno, NV, and chairman of DMAA: The Care Continuum Alliance, which represents the DM/population health industry, says the industry needs to know: What worked? What didn't work? When it did work, why? When it didn't work, why not and for whom?

"We can ill afford to reject looking at any promising solution just as we can ill afford to throw out any favorable baby with the undesirable bathwater from MHS. There has to be some valuable learnings hidden by this sort of blanket up or down evaluation bias that I think has been portrayed in the first two reports," says Norman.

Though the DM industry as a whole remains in the dark about the answers to Norman's questions, the MHSOs did learn from the project and tweaked programs to better serve both the FFS population and their larger patient population.

I talked to two Health Dialog officials about the project and they provided three takeaways the Boston-based DM company learned from participating in MHS:

Target the right people for interventions and support those patients with the appropriate services. Those involved in the project say the FFS beneficiaries selected to take part were from a much broader health status than initially expected. Instead of including only those who would benefit most from a DM program, MHS included individuals from the either health extreme: those who were healthy but suffered a brief health setback when CMS created MHS and those who were at the end of life and institutionalized. Neither of these groups are the typical people who gain from DM programs. Healthier individuals do not need intensive programs, while the sickest are not able to reverse their conditions. To take this to the larger DM population, companies must remember to target the right people with the proper individualized program. Otherwise, the intervention will be too costly and wasteful.

Get timely information so you can reach at-risk and recently discharged patients as soon as possible. Reaching patients shortly after discharge or diagnosis (or even better during hospitalization or when they are at-risk of disease) plays an important role in whether you can change a person's behavior. The MHS project was hampered by a claims lag with MHSOs not receiving timely hospitalization and medical claims data. Not connecting with beneficiaries promptly meant some beneficiaries' health slipped further, making effective change difficult. Waiting until after that window of opportunity is closed means the person most likely won't be at their highest level of activation and you have lost your best chance.

Providers are an important part of the healthcare team. On its surface, this seems like a no-brainer, but it's a fairly new concept in DM. The industry has learned that in order to achieve lasting behavioral change DM must work together with a patient's physician. This is a key tenet in the medical home model, which CMS will test with its own demonstration starting in 2010. Collaborating with physicians and supplementing patient care with DM programs can close gaps in care, and create a complete healthcare team rather than segments not working together and potentially relaying varied messages to patients. If DM is to remain an active part of healthcare, its future is in supplementing provider care through a sort of medical home model. It can no longer expect to improve patient outcomes and lower health costs without physicians on board.

Those three learnings are exactly what DM needs to hear, but so far CMS has not included that information in its interim reports. MHS' final report will analyze all three years of MHS. It isn't expected until February 2011, which gives CMS two years to develop a report that delves into each of the interventions and provides specifics about what each MHSO offered and how it affected care, outcomes, and costs.

That doesn't mean DM should wait for CMS though. This bump in the road should show the industry that it needs to fund research to test its offerings so the healthcare system as a whole can see what works best for particular disease states.

As I wrote in my column last week, if DM expects to play a role in healthcare reform, the industry must look critically at its programs. MHS' interim results show that questions remain about DM.

The industry can't wait for the final MHS report and hope that the results are better. It must take action now.