Disease Specific Program - Case Study Example

DISEASE MANAGEMENT Disease management is “a system of coordinated health-care interventions and communications for populations with conditions in which patient self-care efforts are significant” as defined by the Disease Management Association of America (DMAA). (Sidorov, 2006, p. 259). Chronically ill patients like diabetics, athmatics, heart patients and hypertensives are the beneficiaries of this program. The insurance companies have a tendency to sponsor people with chronic disease in the hope of improving outcomes. The patient could benefit from a build strategy where the insurer directly deals with the consumer or a buy strategy where the insurer secures it from a for-profit organization. Quality is increased and the claims cost is decreased for the patients with diabetes mellitus, asthma, coronary artery disease and chronic obstructive pulmonary disease (Sidorov, 2006, p. 259). Disease management is widely available in the US. Typical program components Reformers of the health care system have a consensus on what they expect from managed care. Their goals are low annual inflation of costs, elimination of the rising health plan premiums, a value-based competition in health care and a new concept of incentives for life time care against the prevalent insurance for episodic care (Coile, 2000). Transition strategies look towards a Sixth stage for managed care. Health plans, providers and purchasers need to expand their levels of cooperation to reach that optimal stage. Three insurance companies, Humana, Oxford and United Healthcare have announced the development of a common physician credentialing application. (Coile, 2000). Administration problems are lessened for doctors and overhead costs are streamlined. The strategies for the Sixth stage may change the health care system and disease management. They are elaborated below 1. Long term agreements The short term profit-oriented current managed care is to be replaced by long term contracts with managed care plans. The long terms should be able to have objectives of quality, outcomes and improvement. Incentives may have to be restructured. Current plans do not give due importance to preventive services and health promotion. Long term agreements could include long term objectives of quality, outcomes and health improvement. Restructuring of incentives may have to be done to stress upon the long term benefits. Purchasers also may have to think on long term basis which is not an easy transition. Business is competition. Mere cooperation to bring about a change to suit policy makers is not the rule (Coile, 2006). 2. Strategic business relationships Strategic business relationships help to build voluntary cooperation between providers and health plans. The current cold war between the plans and providers need to undergo a change. Advanced markets are showing warmth settling in already (Coile , 2006). In many such relationships, the health plan has only provided the financial support but allowed the hospital to do its own management which is definitely a mellowing of principles. Community concerns are thereby managed by the hospital. Business partnerships are also coming together to jointly acquire and manage assets of Health systems and hospitals. Implementation of disease management programs have helped to reduce the expenditure by 7.5 million in the first year in the Western Pennsylvania system (Coile, 2000). There were four disease management programs in asthma, congestive heart failure, diabetes and hypertension. However quality does not always cost less. 3. Empowerment of consumers Consumers who are empowered and well informed contribute significantly to the self management of their illnesses. Asthmatics, diabetics, hypertensives and arthritics are described as “time-bombs” for managed care (Coile, 2000). Information therapy through the Internet can be considered the single most effective weapon in the war against disease. About 10000 to 15000 websites have been set up by health care providers, support groups and pharmaceutical companies. There is no dearth of health advice. Disease management programs for the chronically ill could provide them optimal health for a quality survival. Personal electronic medical records allow consumers to have an updated record always (Coile, 2000). 4. Risk sharing Managed care must have a risk-sharing rather than a risk-avoiding model (Coile, 2000). Plans and providers manage the health of the patient economically. Capitation arrangements are shifting the risk from the plan to the provider. Costs can thereby be predicted. In other more sophisticated arrangements, the plans and providers both jointly hold and cooperatively manage the capitation for long term contracts. This collaboration addresses the weakness of both parties and put in place mutual assistance mechanisms. The providers have lesser administration costs and are encouraged to cooperate with health plans or help in the pharmacy cost control (Coile, 2000). Plan-provider cooperation is exhibited in the sharing of data warehouses and information system investments. Data sharing, cost management and immediate payment claims are facilitated through low cost internet connections. Actuarial support, toll free 24-hour consumer call centers help to access health information, “supply benchmarks for provider performance and provide reinsurance to providers” (Coile,2000). The combination of risk management with best-practice disease management help to create a sustainable managed care movement. 5. Information enabled process The efficiency of the future managed care will be having easy Internet access with computer work stations and cellular communications. Continuous computer monitoring is possible. Plans and providers can manage their operations efficiently and keep up with every process of clinical management and administration. (Coile, 2000). Phsyicians are able to be in contact with patients. Fund-raising is facilitated. Managers can do their job of monitoring costs, inventories, staffing, service utilization and other key functions. A wider range of doctors, patients and hospitals can be brought under a wing for administration. 6. Risk management and disease management Upstream intervention where disease management is blended with early intervention and health improvement has been the system in Pennsylvania (Coile, 2000). A team of experts identify 4 or 5 factors which make the difference between average care and excellent care and builds protocols around them. 31 such programs have been churned out by the Pennsylvania system. Treatment pathways are then designed. 7. Health improvement The optimum goal of the health system is health gain and not health cost reduction. Health prevention and promotion are now given importance by employers. Child immunizations and annual mammograms for women are addressed with greater importance. Financial incentives are being provided. Cooperative projects focusing on health improvement are in place (Coile, 2000). 8. Competing on quality Quality has become important in the purchase of health plans. The best plans and the best quality providers are chosen by the buyers. However quality has not been defined appropriately. Initiatives are being made for quality measurement (Coile, 2000). 9. Community Health Managed care has failed to include community health issues and preventive measures. Efforts are being made to change this attitude. Community health needs assessment is being done now. Teen pregnancies, obesity, smoking, workplace health and safety, problems of retirees can now be included in health plans. 10. Universal coverage “Universal coverage, premiums of reasonable price, managed care health plans, freedom to select providers” all contribute to an utopian idea which could be on the stands before long. A workable programme for diabetes mellitus Full service disease management programs have six components. They are population identification processes, evidence based practice guidelines; collaborative practice models, patient self-management education; measurement, evaluation and management of process and outcomes and finally routine reporting and feedback loops (DMAA, 2006). Current weaknesses are to be identified and strengthened. The strengthening of the doctor-patient relationship is a main goal (Development of a concept, Joanneum Research). The practitioner who is considered the gatekeeper in the health care system is to reinforce his actions and functions. A seamless link between the different disease managements would be created. Patients with multiple illnesses would be included in the programs. The care system would be modified for long term improvements of diabetes mellitus patients (Development of a concept, Joanneum Research). An acceptable model for onsite and off -site disease management for chronic illnesses like diabetes mellitus for optimizing care of patients is the hybrid disease management model (Cavanaugh, 2007, p. 73). The current prevalence being 8%, it is the leading cause of blindness in adults between 20 years and 74 years. Diabetes is the primary diagnosis for 500000 hospitalizations in the US every year. By 2030, more than 350 million people would be affected by Diabetes (Cavanaugh, 2007, p.73). An onsite disease management program has the components of target population, program intervention, providers who deliver the intervention and the environment or setting of the intervention. The onsite evaluation has the advantage of avoiding the possibility of taking advantage of the patient (Cavanaugh, 2007, p. 74). However this direct valuation could elicit the stressors or risk factors for the progression of the diabetes. Patients with diabetes usually have other accompanying illnesses like cardiac illness, renal illness, lung disease or hypertension and so they need a more complex chronic disease management which had better be on-site. Quality improvement interventions include “patient education, promotion of self-management, patient reminder systems, case management, team changes, use of an electronic patient registry, facilitated relay of clinical information to providers, and continuous quality improvement” (Cavanaugh, 2007, p. 75). Collaboration and coordination among multiple practitioners is possible with on-site management. Behavior change among health providers is a significant transition. The health providers could vary from physician, to nurse or pharmacist or social worker or diabetes educator. The environment must be adequate for provision of services for the diabetes patients. Physician attitude towards disease management. Disease management is an approach to health care which may be approved of by physicians (Sidorov, 2006, p. 259). Peer reviewed literature is also indicating that disease management significantly improves the clinical quality of health care. Primary care is an area where disease management can improve practice efficiency. Future developments could even improve pay packets by work performance and quality achievements. Similarly future versions of disease management plans could help the consumer pay less for treatment. Physicians, sponsors and suppliers of disease management services may select the best and most economic approaches to care when the disease management and the chronic care model fully evolve. (Sidorov, 2006, p. 259). Physicians with outpatient clinical practices in the US are facing many problems and dissatisfaction. Reducing incomes and administrative difficulties are rampant (Mechanic, 2003). This makes them wary of new healthcare initiatives. Increasing number of chronically ill patients are being cared for by primary care physicians (Rothman, 2003). However the visits are usually limited to the minimum where quality is sacrificed. Research has indicated that these chronic patients hardly use their medicines or inconsistently use them. The quality of management is affected due to the lack of physician communication, inadequate reinforcing of medical knowledge, missed appointments and poor record keeping (Maguire, 2002). Disease management would fill these gaps. Nurses who are the non-physician health educators step in to motivate these patients. In disease management patients are motivated to provide self care management. These nurses provide the consumer friendly information apart from investigating barriers to care and promoting interactions between the patient and physician which may range from a face-to-face meeting or by telephone or text messaging or web based interaction (Sidorov, 2006, p. 260). Many physicians are resentful about the disease management and do not want it to interfere in their practice. Self care strategies may not be accepted by the doctor. Physicians are also wary of the day when disease management companies may interfere with their treatment and start asking questions when their only concern is business. Some physicians consider that their responsibility and practice would become eroded with the set pattern of management. Quality is definitely better when the disease management is combined with physician care especially in patients with chronic illnesses (Weingarten, 2002). The achievement is enhanced by the added physician care. This would mean that disease management alone may not have the desired results. It would be better to perceive the disease management as a support for practice that improves clinical outcomes (Sidorov, 2006, p. 260). Disease management would result in more of patient self care and sheds some of the responsibility from physicians and their staff. Motivational interviewing is necessary to impart the knowledge on self care. This is not possible in a primary care setting as plenty of time is needed and the reimbursement is not worth the effort. Allocating the disease management vendor with this training for self care or placing more physicians at the disposal of patients may produce a better outcome (Sidorov, 2006, p. 260). Finally it is the physician who is going to benefit as his pay for performance increases and the cash flows at the office grows. Investments can then be made for a higher quality of service. Disease management still being a young industry, many accreditation programs are available. The discussion of the relationship between the disease management and physician is an ongoing topic of discussion. Providers of disease management are interested in improving this interaction (Sidorov, 2006, p. 260). With the costs of electronic records diminishing greatly, physicians have a greater chance of communicating better with patients due to on-screen prompts, physician order entry into records, easily extracting lists of patients for interventions and remote messaging (Sidorov, 2006b). Disease management may be included in this novel idea. Patients with care gaps having a greater risk may be detected for the disease management protocol. Companies are attempting to interest physicians in the pay for participation program and compensation is being provided for patient identification, referral, enrolment, reporting and follow -up (Sidorov, 2006, p. 261). Future versions of the consumer-directed health plans (CDHP) are attempting to meet the drawbacks of the present plans. These old plans do not address the difficulty of chronically ill patients who exhaust their tax-free accounts for care and have to spend from their own pocket or take a costly insurance. The new plans would work for greater interaction between the disease management and the physician practice Vendor evaluation The insurance companies or the disease management vendor can help to improve the health and medical outcomes of the beneficiaries. The vendor can help improve the services to the beneficiaries, ensure that more care is delivered and improve the financial and service results (Vendor Management, FBP Insurance). He can conduct high quality, consistent and cost-effective education and coaching on the medical conditions that they have. Identification, assessment and ongoing telephone contacts are measured against the best-in-class results of the disease management industry. There are companies which can evaluate a vendor, specific disease management programs, identification and assessment of beneficiaries. They can also assess the quality of services rendered and the impact on health costs. Companies that are self funded are cost effective. Detailed medical claims are accessed by self funded companies only (Vendor Management, FBP Insurance). They are also able to estimate the impact of the disease management programme on the medical claims cost. Employers get the maximum returns on their investment by making vendors accountable for promised outcomes. The accountability of vendors prove useful and paying especially in large case management. Really ill patients account for only 1% of enrolment but they account for 25% of total claims cost. Selecting a vendor who can help to keep these costs down is therefore useful. A complete evaluation and intensive continuous contact by a good vendor would mean that he is going to ensure that the case had evidence-based protocols for disease management and the best doctors in his list treated the case and that the treatment was at the best hospitals available (Vendor Management, FBP Insurance). Having such a vendor in one’s services would produce the best outcomes and a huge saving on claims costs. Economic Impact on the organization Disease management programs are considered to have a positive economic impact if the return on investment is good. Calculation of returns is fairly easy though no standards have been formulated for appropriate calculation of cost savings Cousins, 2003, p. 208). Disease management costs vary from nation to nation and hospital to hospital. The cost in a successful diabetes management programme in a primary care setting was US $37 (Rothman, 24) In a Scotland hospital the costs came to an equivalent of $143 -185 when traditional care itself cost $101. Numerous hospitals have reported savings from reduced costs. These were constituted by direct reduction of hospital costs (Rubin, 1998), healthcare utilization, improvements in the quality of care and reduction of indirect costs by reduced number of complications (Sadur, 1999). Where diabetes is concerned, the improved glycemic controls and expected savings may take several years to become consistent. Disease management programmes may take years to provide a positive outcome. Only few studies have really evaluated disease management programs (Cavanaugh, 2007, p. 77). The advantages and disadvantages of outsourcing in a disease management program. The outsourcing to a disease management company reaps benefits which include. good financial returns and better quality patient care. Call management systems and support tools would be in place. Measurement reporting would be thorough (Insourcing versus outsourcing, Healthcare Marketplace). The company takes pains to educate patients in self care. Electronic health records would be used. An efficient information system would be working. The pay for performance may be better and physicians may be highly paid (Sidorov, 2006). Community health would be given due importance. Doctors have lesser administration problems. Overhead costs are streamlined. The disadvantage is that physicians may worry that they may be questioned by the company if they stray from the established pattern (Sidorov, 2006, p. 260). Research suggested As the topic of disease management is a fairly new one, not many studies have evolved over the years. A meta-analysis appears to be the method possible for a research. Information may be gathered from a minimum of 10 disease management programs in various parts of the country or the globe. References: Coile, R. (2000). “The Sixth Stage –A Health Management Model for tomorrow’s health care system” Chapter 12 in “New Century Health care: Strategies for providers, purchasers and plans”. Health Administration press. Cousins, M.S. (2003). “Cost Savings for a Preferred Provider Organization Population with Multi-Condition Disease Management: Evaluating Program Impact Using Predictive Modeling with a Control Group”. DISEASE MANAGEMENT Volume 6, Number 4, 2003 Disease Management Association of America. DMAA definition of disease management [online]. Available from URL: http://www.dmaa.org/definition.html Development of a concept for Disease Management in Austria, http://www.joanneum.at/?id=987&L=1, Joanneum Research Maguire P. Strategies to tackle outpatient errors [online]. ACP-ASIM Observer 2002 Jun. Available from URL: http://www.acponline.org/journals/news/ Matheson D, Wilkins A, Psacharopoulos D. (2006). “Realizing the promise of disease management: payer trends and opportunities in the United States” [online]. Boston (MA): Boston Consulting Group, 2006. Available from URL: http://www.bcg.com/publications/files/Realizing_the_Promise_of_Disease_ Management_Feb06.pdf Mechanic D. Physician discontent: challenges and opportunities. JAMA 2003; 290: 941-6 Rothman AA, Wagner EH. Chronic illness management: what is the role of primary care? Ann Intern Med 2003; 138: 254-61 Rubin RJ, Dietrich KA, Hawk AD. (1998) “Clinical and economic impact of implementing a comprehensive diabetes management program in managed care”. J Clin Endocrinol Metab 1998 Aug; 83 (8): 2635-42 Sadur CN, Moline N, Costa M, et al.(1999). “Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits”. Diabetes Care 1999 Dec; 22 (12): 2011-7 Sidorov, J. (2006). “Disease Management and Its Implications for Outpatient Physician Practice”. Dis Manage Health Outcomes 2006; 14 (5): 259-263 1173-8790/06/0005-0259/ Sidorov J. (2006b). “It ain’t necessarily so: the electronic health record and the unlikely prospect of reducing health care costs.” Health Affairs 2006; 25: 1079-85 Vendor Management, Retrieved on 25/1/09, serviceshttp://www.preceptgroup.com/services/hms/vendormanagement.htmls FBP Insurance Weingarten SR, Henning JM, Badamgarav E, et al. Interventions used in disease management programs for patients with chronic illness – which ones work? Meta-analysis of published reports. BMJ 2002; 325: 925 Read More