This year has not been kind to disease management.
Experts have increasingly questioned DM's effectiveness and CMS ended the DM-inspired Medicare Health Support demonstration, claiming that it was not successful.
Those who question DM say call-center based nursing programs are simply not cost-effective, which is causing many in the industry to find other ways to reduce costs and improve outcomes and quality.
Employers are also demanding services that reach all employees (not only the sickest), and DM companies have found that DM programs are not as effective for some chronic illnesses.
This combination has led DM companies to add wellness programs to their chronic care offerings and create an expanded industry now called population health, which has replaced disease management as the industry term.
Population health companies have moved beyond call-center programs and expanded into technology, remote patient monitoring, and automated call centers.
At the recent DMAA: The Care Continuum Alliance conference in Hollywood, FL, two industry leaders discussed another potential option: chronic illness self-management.
The healthcare system does not prevent illness and disease; empowering the individual patient to take control of his or her health could become the next frontier for DM, said Kevin J. Wildenhaus, PhD, director of behavior science and data analytics at HealthMedia Inc. The Ann Arbor, MI-based company, which was purchased by healthcare giant Johnson & Johnson in October, specializes in combining technology and behavioral science to emulate a health coach via the Web.
Chronic illness self-management programs move away from member education to empowerment and away from information to intervention, said Wildenhaus.
It's one thing to place health information on a Web site. It's quite another to make it informative and something that people can integrate into their lives. This can be accomplished by gathering information from an individual's health risk assessment and claims records, and then creating a member-specific Web page. Employers can help by giving incentives for employees to visit their pages.
"The information is out there. People are accessing it, but what are they doing with the information," said Wendy Vida, RD, clinical preventionist at Highmark Blue Shield in Pittsburgh. Highmark created the Blues on Call program that seeks to empower members through a 24-7 condition management program, interactive voice recognition telephonic outreach, resources for members and providers, self-management education, nurse case management, and online chronic condition program.
Vida said self-management is especially important given the growth of consumer-driven health plans (CDHPs). Having to take a greater responsibility for their healthcare bills, people must gain a better control of their health and self-management dovetails with CDHPs, she said.
Wildenhaus said self-management programs include:
Management of medical, emotional, and personal issues
Motivation and self-confidence associated in managing their conditions
Management of sleep, pain, fatigue, and depression
Improved doctor, patient, and pharmacist relationships, and communications
Medication adherence and overall treatment compliance
Social support
Setting goals and planning skills
Accepting personal responsibility for managing conditions
Wildenhaus said both Highmark and HealthMedia's programs get people engaged, improve patient conditions, and reduce medical and productivity costs. For instance, participants reported improved health, quality of life, self-confidence, self-management skills, provider relationships, and medication adherence as well as decreased stress and worry. A medical claims analysis showed that the Highmark program saved nearly $1,000 on medical claims per each member annually compared to projections.
HealthMedia has been successful in areas such as depression, insomnia, and eating disorders, but there are a whole slew of barriers to overcome if self-management becomes the norm across the population health landscape.
Here are just a handful of questions:
Will doctors view this as a direct attack on their autonomy?
How can you help at-risk populations self-manage their conditions?
What do you do with the millions who are not ready to commit to better health?
Will health insurers, population health companies, and technology vendors be able to create networks that effectively engage members?
How much will human intervention (i.e. nurse call centers) play a part in self-management programs?
The industry is interested in learning more about the idea as was evident in the packed meeting room when the two industry leaders spoke.
However, there are still many unanswered questions about how to make health a part of everyone's daily life. Integrating health into lives will take a coordinated effort from all stakeholders, including physicians, population health, health insurers, nurses, and most importantly the patients.
A person has to feel motivated before he or she is activated. That activation level for each individual will ultimately decide whether chronic illness self-management is a winner or another interesting idea that doesn't work.
Les Masterson is senior editor of Health Plan Insider. He can be reached at lmasterson@healthleadersmedia.com.Note: You can sign up to receiveHealth Plan Insider, a free weekly e-newsletter designed to bring breaking news and analysis of important developments at health plans and other managed care organizations to your inbox.
The medical home healthcare model is going mainstream. Commercial health plans and employer groups are continuing to show interest in the potential value of the medical home approach.
Driving some of the interest is the increasing prevalence and associated costs of chronic conditions in the United States coupled with the growing shortage of primary care clinicians. Primary care providers, health plans, and disease management companies all focus benefits and services on improving health outcomes while trying to contain the cost of care provided.
Since all these players ultimately appear to have common goals, the medical home model seems like a natural progression toward effective care collaboration. As this care model has continued to progress from the government to the commercial space, some of these organizations fear that the need for their services, especially in the areas of case management, disease management, health coaching, and wellness activities, will diminish rather than flourish. Realistically, there will be a continued place for them in the medical home.
While the primary care provider is the captain of the medical home ship, in many cases they don't have the resources, expertise, or capital to hire those necessary to provide complex care. In order to fill this void, they will need to partner with health plans, and case management and disease management companies to provide these types of services.
Rather than feeling competition from primary care providers, health plans should be interested in attracting and retaining providers with the necessary desire and skills to coordinate care for patients across the healthcare continuum. Adding primary providers increases the number of potential office visits, resulting in more revenue for the health plan and decreased overall healthcare expenditures.
Bringing together the efforts of a multi-disciplinary team further reduces cost of care through avoiding duplication of efforts and more effective use of resources. Ideally, a multidisciplinary team works closely with the primary provider taking collective responsibility for the ongoing care of the individual while sharing complex sets of tasks.
Care coordinators, and case and disease managers working with the primary provider can partner with the patient to act as advocates for their patients, supporting optimal, patient-centered outcomes. The synergy of primary providers, health plans, and disease management organizations working together with shared care plans, driven by evidence-based interventions, offers the opportunity for organizations to redefine how programs integrate while monitoring and managing at-risk members.
Concern has arisen as specialty providers, such as case and disease managers, have felt that their services could be replaced by the medical home model. Yet it is estimated that in our current healthcare system, the average primary care physician only spends about an hour with a patient per year. That is not an adequate amount of time to treat illnesses, provide proper preventative care, assess for social and educational needs, identify and implement interventions, as well as educate the patient.
This offers a great opportunity for primary care providers to team with existing health plan and care management staff to create efficiencies that should lower the cost of care for most patients while affording physicians more time to provide the quality care their patients and payers deserve.
A critical, yet costly component in the medical home model is the adoption of technology, such as electronic health records. While potentially out of reach for the average provider, partnering with health plans or care management organizations that have existing technology infrastructures opens additional options, such as cost sharing, putting this option within reach of the provider.
The tracking of performance measures for quality reporting becomes more accurate and efficient when system-driven analysis is possible. Prospective data collection becomes a reality providing the primary care physician with essentially real-time quality measures for the purpose of benchmarking and improvement. Information technology, such as Web portals, offers new and innovative ways for care providers to communicate with their members.
While the shift in focus toward medical home models in commercial populations holds promise for improved quality of care and cost savings, it is not without significant obstacles for adoption. Without payment systems that appropriately recognize the added value provided by the medical home healthcare model and technology systems to support communication and coordination between entities, the real potential of a medical home will not be realized.
Jo Anne Hunt, ARNP, CCM, is director of clinical solutions at Casenet, Inc., a Bedford, MA-based provider of care management software solutions.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
The Connecticut Insurance Department says it has not received any company proposals for higher malpractice rates in 2009, and some physicians may even see some premium decreases as a result of credits for being claim-free. "We are very pleased that the actuarial rate indication remains unchanged," Denise Funk, Connecticut Medical's chief executive, said in a prepared statement.
Two West Tennessee hospitals have agreed to a $7.9 million settlement for overbilling Medicare, according to federal investigators. The U.S. attorney's office in Memphis, TN, said in a statement that the settlement covers "false claims to Medicare" from Jackson Madison County General Hospital for ambulance services and from Milan General Hospital for geriatric psychiatric care. The Jackson hospital agreed to pay $2.6 million, while the Milan hospital agreed to pay $5.3 million.
A new index launched by Nashville-based revenue cycle management company Emdeon would track the healthcare industry's move to an electronic system from a paper-based and phone-based one. The company has unveiled the U.S. Healthcare Efficiency Index, saying it aims to raise awareness about potential for cost savings on the business side of healthcare. For example, it estimates $11 billion could be saved a year through direct deposit of medical payment transactions.
Powerful special interest groups that helped sink healthcare reform early on in the Clinton administration are now advocating significant changes in the nation's health insurance and delivery system. They are participating in regular discussions about how to expand health coverage and lower costs.