Monday, April 14, 2008

The Urban Group Symposium, Primary Care and the Revealing Spontaneous Comments Opposing Disease Management

Leaders in the disease management industry may want to check out this April 4 video from a symposium entitled ‘Shock to the System: Preparing Primary Care for the Baby Boomers.’ It was hosted by the Urban Medical Group of Massachusetts and featured Richard Knox of National Public Radio, Harvey Fineberg of the institute of Medicine and Thomas Bodenheimer of the Department of Family and Community Medicine at UCSF. A transcript is also available for download.

Kudos to the Kaiser Network for making such links so readily available.

After a quick tour of health sector central-planning German style, U.S. babies’ needless suffering, the evils of insurers’ administrative costs hampering the delivery of high quality care and the enduring failure of medical education, it was Dr. Bodenheimer’s turn to preach to the choir.

He made some interesting points about primary care and chronic illness. He concludes the reliance on the 15 minute primary care visit as the one-size-fits-all vehicle for all health care needs is woefully inadequate. It has been victimized by dysfunctional fee schedules, perpetuates the tyranny of the urgent and promotes a hamster-wheel syndrome in which there is no time to do any preventive care. For persons with chronic illness, this is a disaster.

According to Dr. Bodenheimer, it doesn’t need to be this way because three solutions are at hand. The first is ‘panel management,’ which is registry-based, delegated management of an entire clinic’s population independent of the office visits. The second is ‘care management,’ which relies on non-physicians who can provide intensive individualized nursing for persons with complex health care needs. The third is coaching, which helps people get the information and skills they need to take care of themselves.

So where was any mention of disease management? It was conspicuously absent until the Q&A, when there was a last question from an unidentified audience member on whether insurers should be involved and if so, how it could be partnered with primary care physicians taking on a more coaching model.

Check out Dr. Bodenheimer’s reply:

‘I don’t have any research to back this statement but I’ll make the statement. I think of all the money that was spent on disease management companies were spent to do the similar kind of things in primary care, it would be much more effective [applause]. There is some research that shows that people working with disease management met the people face to face, it’s more effective than just phone calls….. I don’t like these long distance phone calls. Some of these disease management companies have come up with some good stuff but I think it could be done more effectively in primary care.’

As a public service, the Disease Management Care Blog would like to offer up some research for those other health care leaders who may like to have research to back up statements. Remember that ‘Is $1 Billion a Year a Good Investment’ article by Mattke and colleagues from the American Journal of Managed Care? That review could hardly be called supportive of the industry, but based on data from 29 studies, the authors concluded:

‘Across all conditions except asthma and COPD, there is consistent evidence that disease management can improve processes of care (eg, increased A1C screening for persons with DM). The results of the studies suggest that improved clinical care seems to lead to better intermediate outcomes and improved disease control (such as lower A1C levels in persons with DM), which was demonstrated for CHF, CAD, DM, and depression.’

In addition, Dr. Bodenheimer and many of his colleagues may not ‘like’ long distance phone calls, but a more important question is what do the patients like? The disease management industry has been asking that aplenty and one answer from one representative study (there are many others) from McKesson is:

Over 90% of program participants report themselves as being "satisfied" or "very satisfied" with the diabetes management program in an independent satisfaction survey.

To the knowledge of the DMCB, there are no head-to-head studies comparing primary care based panel-care-coaching versus telephonic-based disease management. That would be the evidence-based approach necessary to decide if 'the money' should be spent on primary care instead of disease management companies. However, that’s a moot question.

What’s more important is the original question from the unknown audience member mentioned above: … it could be partnered with PCP’s taking on a more coaching model.

That question still stands.

Post script: The applause from the audience was a telling commentary on the lingering gulf that exists between the part of the physician community represented by Urban Medical and disease management. Since scientific evidence seemed to be conspicuously absent in the anti-industry comments from a leading scientist, the DMCB is coming to wonder if any amount of additional research will win provider hearts and minds. A new approach may be needed.

That’s for another post.


Adam Greene said...

Thanks Jaan for this post. There is some fantastic stuff here and plenty to ponder. I'm glad I stumbled across your blot!

Jaan Sidorov said...

Thanks for the supportive comment Adam.

Unknown said...

I am not necessarily a supporter of "big DM" but let's face it, doctors are the ultimate craftsman and don't like a production model. DM incoporates some elements of a production (factory) model, and its well worth understanding what these are, and how they may contribute to better outcomes.