Congressional Budget Office Says Disease Management May Well Be Cost Effective

On February 25 2009 CBO Director Douglas Elmendorf gave testimony before the US Senate on options for expanding health insurance coverage and controlling costs. It's an impressive 31 page document that effectively describes a host of healthcare reform policy options. The Disease Management Care Blog found some statements about - what else - disease management. The most important quotes are below.

Note that overall, CBO is still describing the industry in supportive terms.

'...disease management services can improve health and may well be cost effective - that is the value of the benefits could exceed the costs. But those efforts may still fail to generate net reductions in spending on health care because the number of people receiving the services is generally much larger than the number who would avoid expensive treatments as a result.'

The DMCB agrees that considering the merits of health care interventions based on their ability to 'save money' is less useful than assessing them on how well they deliver value. Contrast nurse-based coaching aimed at achieving an A1c of 7% (which is typically poorly covered outside of managed care settings, if at all) versus stents for persons with coronary artery disease. Both result in betterment. Both cost. One delivers far greater benefit than the other.

As for the dilution of disease management interventions over large populations, organizations in the business of population-based care management have known about this for a long time. In response, they use predictive modeling to target beneficiaries who are most likely to benefit from the interventions. For this to work, however, the Medicare program will need to consider the implications of unevenly applying a benefit to an eligible population. The DMCB has an ironic paraphrased quote to think about in these these days of expanding central government: from each according to their ability, to each according to their need.

...proposals could include specific elements designed to induce individuals to improve their own health or to encourage changes in how disease are treated. Through a combination (bolding mine) of approaches, proposals could try to change the behavior of both patients and providers by promoting healthy behavior,.... expanding...preventive care, establishing a medical home..., adopting 'disease management' programs,... funding research comparing the effectiveness of different treatment options... expanding the use of health information technology... and modifying the system for... malpractice. In many cases studies... studies do not support claims of reductions in health care spending or budgetary savings.

Not quite. Many of the studies in each of the domains above are restricted to just that domain (for example, just the medical home) or to a particular piece of the domain (for example, the use of physician order entry). There are few, if any, studies that examine the impact of any significant combination of approaches (for example, the medical home plus telephonic-based coaching that promotes the latest effectiveness research findings linked to a personal health record). The DMCB thinks combinations of these interventions will be proven to be greater than the sum of their parts. This will be the next frontier for effectiveness research in population based care, Medicare demonstrations and Medicaid waivers. In addition, this is where we'll see innovations in those pockets of the medical insurance market place left untouched by the Federal tsunami.