Friday, September 12, 2008

The Five Ugies of Disease Management

Almost everyone has heard the term ‘the good, the bad and the ugly,” based on a movie by the same name starring Clint Eastwood. In fact, the Disease Management Care Blog has personally used the GBU theme in a ‘canned Grand Rounds’ lecture on the topic of chronic heart failure (there is Good treatment, it’s still a Bad disease and what Medicare will need to do is Ugly). Well, Brenda Motheral has authored a contentious article on disease management in the Journal of Managed Care Pharmacy that is short on good and bad and long on, not one, but five uglies that are ailing the disease management organizations (DMOs):

Vendor and Client Misalignment – ‘opt-out’ programs generate income in the absence of engagement, which tempts DMOs to cut costs to maximize profits. Solutions include minimal staffing guarantees, performance guarantees and using opt-in approaches.

Insufficient Transparency – engagement definitions, intervention methods and reporting methodologies are not only black box, they differ from vendor to vendor. The solution is, you guessed it, ‘transparency.’

Wanting Plausibility – examples include 1) mismatches between the timing of interventions (for example, engagement levels) and the oversized ROI’s as well as 2) suspect correlations between the changes in process/clinical measures (for example,A1c and LDL) and reductions in ER use and admissions. Rigorous scientific assessments of plausibility are needed.

Substandard Evaluation Methodologies – This has been an historical Achilles Heel that has hampered the establishment of a causal link between what DMOs do and what DMOs claim. The argument that there is a trade-off between rigor and practicality is dismissed as not holding water. Even worse, establishing links between wellness/prevention and outcomes like absenteeism is even more daunting.

Where’s the Convincing Evidence – you’d think it would have shown up by now, thanks to ten years and tens of millions of enrolled members. What we do have is a publication bias combined with a stubborn lack of conclusive proof. Maybe an industry-wide commitment to find the proof once and for all is necessary or maybe it should be a matter of assessing the impact on quality of life for the dollar spent.

So just how does one reconcile this piece and the article written by Gordon Norman? The DMCB isn’t sure you necessarily have to. While DMOs may understandably view non-supportive articles as a business threat, the DMCB believes the scientific literature is supposed to be a contentious bumpy search for the truth. There are no free passes in health services research. Here are your five credibility gaps, says Dr. Motheral, it’s time to do something about it.

In fact, there are many unsung heros in the industry that are doing something about it. The DMCB has witnessed rigorously defined guarantees in contracting. Reductions in ER use and admissions, in the DMCB’s estimation, seem to be a function of difficult-to-measure case management (recall in the prior post, it’s nurses that are the ‘secret sauce,’ not NCQA'oid' A1c measures). The DMAA meeting abstracts and the renamed Population Health Management Journal’s manuscripts have had significant jumps in rigor; we're getting there. The DMCB wonders if the industry should lead the way and start open-sourcing the data behind its conclusions. Finally, the DMCB is detecting a growing appreciation that the industry is moving away from simplistic notions of saving money based on a 1st generation business model to better demonstrations of value, asking ‘what works,’ and changing the care management approach accordingly.

As the industry continues to evolve, let’s hope we better deal with the ugies so ably described by Dr. Motheral.

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