Monday, January 5, 2009

Medicare Health Support Becomes A 'Black Sheep'

Many families have them. The dysfunctional uncle that was in jail. The disreputable cousin struggling with drug abuse. The lazy n’er-do-well brother-in-law. Furtive glances at the dinner table when they’re brought up in front of strangers. Prefer not to talk about them. They’re the ‘black sheep’ and the disease management ‘family’ now has theirs: it’s called Medicare Health Support (MHS). And like that dreaded 2 AM ‘Hi, I’m in town!’ phone call, MHS is inconveniently dropping in with a 69 page update with an additional year’s worth of data.

Recall this is the largest experiment ever involving classic disease management. It’s a Medicare-sponsored, randomized and prospective trial involving eight different disease management organizations (DMOs). They have been paid an average of $67 to $118 per patient per month to manage tens of thousands of randomly assigned Medicare fee-for-service patients with chronic illness in a mix of urban, suburban and rural settings. To assess the impact of disease management, patients are being compared on satisfaction, clinical outcomes and cost to usual care patents that are serving as controls. Participants have to opt in. The goal is to save money or at least break even by reducing Medicare’s claims expense equal to the amount of the disease management fees.

Participation rates were 74-95%; 4-15% could not be reached and the remainder refused. Participants who opted in turned out to be a healthier and less costly subset. In addition, one year later, CMS offered the DMOs the option doubling down by supplementing their assigned populations with additional ‘refresh’ patients. 7 of the 8 accepted, hoping to attract greater numbers of persons with chronic heart failure. By then, LifeMasters had already backed out, but things unraveled after that. McKesson and CIGNA exited followed by XL Health and Green Ribbon requesting early termination of their contracts.

The data has continued to roll in. And what did the disease management family find when they opened the door to the black sheep this time?

Of multiple measures of satisfaction, only 13% showed a statistically significant improvement.

40% of multiple measures of clinical quality showed a modest improvement of 2-4%.

There were no statistically significant reductions in hospitalizations, rates of readmission, or emergency room (ER) visits between the intervention and comparison groups.

No statistically significant differences were observed in mortality rates.

The claims expense trend rate was not statistically different compared to control patients overall or in individual disease categories. After statistically controlling for the differences that developed after randomization, the lack of any difference in claims expense held up. Including the refresh population didn’t make any difference.

Ugh. But, the Disease Management Care Blog doesn’t exactly think it’s all that bad. It has some black sheep in its family and they’re not THAT bad either. Here’s why:

In an ‘ala cart,’ and free-range system of care, it’s becoming very apparent that it's difficult to control/steer/influence Medicare beneficiary behavior. That contrasts with controlled systems with limited networks and creative/restrictive benefit designs. Disease management works best when it’s a part of managed care which still has a significant role to play. How well physicians are able to do this in the Medical Home - absent a 'gatekeeping' approach - remains to be seen.

Secondly, MHS is testing an approach to population-based care that is already becoming obsolete. New approaches with Ver. 2.0 disease management that are better aligned with information systems, benefit designs, consumerism and primary care are already underway. Disease management has already learned what doesn’t work and is applying those lessons in the marketplace.

Last but not least, the DMCB thinks the market and the Feds decided months ago that ‘disease management’ in fee-for-service Medicare doesn’t have much of a future. This latest report is merely a reaffirmation of that.

Everyone knows about the black sheep. Time to move on.

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