Friday, June 6, 2008

More on the 3rd MCCD Report: What Does It Tell Us About Disease Management? Answer: Not Much (Part 2 of 4)

The Disease Management Care Blog read the 3rd Report Third Report to Congress on the Evaluation of the Medicare Coordinated Care Demonstration (MCCD) again, with special attention to what it tells us about ‘disease management.’

The answer is: not very much.

Of the 15 participating programs, 3 were what would be considered “classic” disease management vendors: QMed, Quality Oncology and CorSolutions. Yet, in the opinion of the DMCB, these 3 entities are not truly representative of the current modern mainstream. QMed’s program revolved around the use of its proprietary heart monitor, which detects subtle evidence of coronary artery disease. It relied on physicians to initiate treatment changes. Quality Oncology’s program was postured to manage adverse treatment effects. There was patient education, but little else. CorSolutions was limited to chronic heart failure, provided patient education but appeared to have no home telemonitoring.

In other words, none of the 3 programs appeared to provide the full suite of overlapping tailored care approaches typically seen in full bore commercial DM programs. In addition, diabetes was not included for any of the DM participants.

Only one of the programs (CorSolutions) came close to mirroring what is seen in typical disease management, yet it was limited to chronic heart failure. The DMCB has tackled the topic of heart failure DM before. Success in heart failure is very dependent on targeting the right persons. Mild heart failure patients are destined to do well not matter what, while severe heart failure patients have disease that is implacably progressive. If many patients to the left or the right of the core moderate group are included, any success will be diluted. Given the mean PMPM of >$2000 in the CorSolutions cohort, the DMCB suspects they had a lot of severe patients. The odds were stacked against them.

It gets better though. QMed and Quality Oncology had a -0.2% and -1.9% change (that’s right, negative, in that it dropped) in monthly Medicare expenditures including their fees. Based on the statistics used, the analysis was unable to show this was significant. However, QMed and Quality Oncology contrast considerably with the demo’s overall mean increase of 11.3%.

What’s more, none of the changes seen for any other the groups were significant at a p equals .05 level. The threshold was lowered to .10. If you take 15 programs and toss their outcomes in the air, the likelihood of a spurious change in one of them is probably greater than 10%. Ugh.

While ‘disease management companies’ described 3 of the 15 participating programs, the other 12 consisted of hospitals, integrated delivery systems, academic health centers, long term care providers and care coordination providers. Two providers were (again, p = 0.1) cost neutral: Georgetown University (which also stuck to heart failure patients who also had a high PMPM. They dropped out early but appeared to be doing something right) and Health Quality Partners – a quality improvement service provider located in eastern Pennsylvania. If entities other than disease management vendors supply care coordination services, what do you call it? Is one good name that darling of well-meaning health policy makers everwhere, yes we're talking ‘the medical home?’

What does the DMCB conclude?

Disease management per se was really underrepresented in this apparently unsuccessful demo, and what’s more, the disease management was limited to ischemia monitoring, cancer treatment side effects and a blunt approach to heart failure. Despite that, two out of three seemed to do well. That being said, the DMCB doesn’t really think this demo was about ‘disease management.’ It was about a population approach to care incorporating many but not all of the critical features that make up modern disease management. The MCCD report's inclusion of disease management as the poster child for the lack of savings is really misinformed.

The DMCB notes that the approach to care described in this demo equally applies as badly (if not more so) to the concept of the ‘Medical Home.’ That term is conspicuously absent in this report. Why?

The DMCB still doubts that a randomized clinical trial is the best way to think about this corner of the health care enterprise. The taxpayers and decision makers in Congress deserve better.

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