Wednesday, February 13, 2008

Commentary on Heart Failure & the Medical Home, plus News about Healthways and the Merits of Carve-In-Out-Outs

"Ruh roh," thought the Disease Management Blog, "another negative disease management program report." Grimly steeling himself, he traced down the reference. Its Jaarsma et al: Effect of moderate or intensive disease management program on outcome [sic] in patients with heart failure. Arch Intern Med 2008;168(3):316-324. The entire article is available for viewing (thanks, Archives!)

Over a thousand persons discharged from a hospital with chronic heart failure (HF) were randomly assigned to one of three groups: usual care, basic support (additional outpatient visits with a specialist nurse) or intensive support (visits plus weekly telephone calls, home visits, support from other non-physicians). About 50% were NYHA II and the other 50% were III or IV. During the 18 months of prospective follow-up, there was no statistically significant difference in death rates or hospitalizations across the three groups.

What should readers be aware of?

In the 3rd paragraph of their own published "Comment" about their data, the authors point out that there are two explanations for their negative study: either the intervention didn't work, or the comparison control group did much better than expected. The authors explicitly noted that the surprisingly good control group data "in particular may have an important role." Note that the all of the study subjects received intense coordination from cardiologists in Heart Failure Clinics. Adding a "disease management" program to that mix did little.

The Disease Management Blog also notes this study was conducted in The Netherlands. Issues of culture, access to care and the scope of the insurance benefit make generalizing these results to the U.S. doubtful. Just because it doesn't work across the pond doesn't mean it won't work here.

But, there are two other thoughts I'd like to offer, one methodological and the other about the true nature of the study.

There seemed to be lots of patients with NYHA Class IV disease in this study. Class IV is a sick group and many physicians will tell you that individuals with this burden of disease are extremely fragile and very prone not only to exacerbations of their heart failure but are highly vulnerable thanks to other co-morbidities. They are destined to be high cost no matter what is done. Accordingly, I doubt if usual disease management interventions directed at this segment of a heart failure population are able to garner much of a "return on investment" in mortality rates, hospitalizations, quality of life or claims expense. The same may be true at the other end of the spectrum of disease, where it is not unusual for patients with very mild heart failure to do well for years at a time. The types of interventions described in this article will only "bend the trend" in the mid-spectrum of disease. That's the point of my crudely constructed image.

While I wish I could take credit for this insight about the spectrum of disease, it belongs to Ed Wagner, thanks to his 2004 Annals article.

From a methodological standpoint, the authors were destined to have trouble demonstrating any impact from basic or intensive support because the patient population wasn't ideal: it included patients who were destined to do very well and patients who were destined to do very poorly in all three treatment arms.

Last but not least, who says this was "disease management?" While it meets the commonly held view of a "typical" disease management program, this was really a physician-owned program in a network of hospital-based specialist clinics using an approach much more akin to the Medical Home. Too bad the authors didn't substitute those two words in the title in lieu of "disease management." Now THAT would have been interesting and probably generated a lot more media attention.

And speaking of disease management, some additional bad news for Healthways. The disease management blog recalls the happier times described in this article in Managed Care Magazine. Nothing like an activist State Attorney General to rain on the parade of a state-of-the-art program, even if Minnesota Blue Cross Blue Shield had compelling data showing a beneficial impact on claims expense that was in excess of the high fees. No matter: the AG was on a search and destroy mission thanks to BCBS' other questionable uses of their enrollees' hard earned premium dollars.

Note that this health plan is considering bringing its disease management programs "in-house," not abandon them. They seem to still believe in the concept, and so do the health care analysts quoted in the bad news article linked above. As for going in-house, the disease management blog wishes them good luck. I believe that while there are some good reasons to do that, cost isn't one of them. The ultimate cost of well run "carve in" programs are not that different from the "carve outs." Instead, you get (or rather, the enrollees get) what you pay for.

Instead, I believe the real opportunities for savings in population care will turn out to be blended approaches that use the best of both "carve in and out." The well run disease management organizations are so good at what they do and are unmatched in their delivery of high value, industrial strength, telephonic-based patient engagement. For many patients with some conditions at some stages of disease, that may a perfect intervention.

On the other hand, health insurers may be better able to marshal the kind of local resources necessary for high touch care coordination and case management. For other patients (especially those outside of the Netherlands and without NYHA Class IV heart failure), that may be the perfect intervention. Even better, Health Plans could stand aside and carve this function out ("carve out and out") to the real "on-the-ground"experts in a network of Medical Homes.

The disease management blog suspects the "vendors" understand the potential of "carve out and outs" and are keenly interested in figuring out how meaningfully integrate their telephonic-based programs with the physician community's Medical Home approach. For more on pros and cons of that interesting vision, check out 1) what Vince Kuraitis has to say about the complimentary potential of Medical Homes and disease management and 2) what the DMAA has to say about it.

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