The DMCB asked Jim about the outlook for traditional old fashioned nurse based, ‘telephonic’ disease management. He replied that while the industry is morphing, their programs will always include a ‘telephonic base.’ Since States typically have tens of thousands of beneficiaries that are eligible for care management, there is no escaping the industrial level efficiency supported by a ‘remote’ telephonic outreach. McKesson is working to make its telephonic care programs better while simultaneously pairing them up with additional community-based, provider-‘embedded nurses’ who in turn become part of the local health care teams (or, if teaming is absent, catalyze its creation). In fact, Jim suspects more and more RFPs are headed in that direction.
DMCB comment: it’s one thing for advocates of the Patient Centered Medical Home to talk teaming, it’s another thing to have a nurse parachute in and make it happen.
The DMCB next asked what explains the disconnect between skeptical public policy and the persistence of State DM programs? Are buyers smarter? Using different metrics? Jim thought that because the States have been doing this for a long time, their measurement methodologies have become more established and that there is often a high degree of mutual accountability. Jim felt Medicaid purchasers are smarter, savvier, more experienced and know how to navigate DM’s clinical and financial outcomes. What’s more, States also are very willing to share insights with each other via learning collaboratives, various formal meetings and other informal communication channels.
DMCB comment: It remains to be seen whether the architects of national health care reform will tap into this knowledge base.
The DMCB also asked about impact of ARRA and the Medicaid supplemental funding on States’ DM programs. Jim replied that since States are having significant budget crises, it’s unlikely that more money will be pumped into new chronic illness, wellness and prevention programs. Rather, the funding will be used to plug budget holes in existing programs. Any money left over may spur investment in programs aimed at controlling the trend in high cost subpopulations. An example may be waiver groups.
The DMCB thinks this is interesting. If the Administration’s economic forecasts turn out to be too rosy, future interest DM programs may be spurred by the pressing need to address uncontrolled costs rather than notions of quality or value.
Finally, the DMCB has about the role ‘risk-based' DM contracting. Jim pointed out that every deal currently has fees that are at risk for both financial and clinical outcomes. This is not going away, but it has stabilized with few contracts having upside gain sharing but most having a floor. In McKesson’s instance, there is enough at risk in most programs that ‘they have our attention.’