Sunday, February 7, 2010

Business Week and Disease Management: A Closer Look

The Feb. 4 Business Week has an article on disease management provocatively titled ‘Take Your Meds, Exercise – and Spend Billions.’ The accompanying graphic displays a circa 1950’s nurse pointing to a Rube Goldberg contraption that ends in cash being shredded.


The article opens with a description of General Electric’s disease management (DM) misadventure and contrasts that with the seemingly inexplicable $2.5 billion commitment of 75% of the nation’s large employers to the DM industry. Even more mysterious to authors Chad Terhune and Arlene Weintraub is the success of ‘industry lobbyists’ in convincing the Obama Administration and Congress to include some version of DM in health reform. They credit a vast lobbying operation, fanciful marketing, exaggeration, lack of scrutiny and the dissemination of biased insider studies. And what unfriendly news article on DM would be complete without dredging up the hapless Medicare Health Support study. Alas, says the expert-critics that are quoted in this piece, tobacco cessation and exercise promotion have no return on investment, it's all waste, it's all money down the drain!

To the reporters’ credit, they did take the time to interview industry veterans who recycle many of the Ver. 1.0 arguments in favor of disease management: 1) the fact that employers and Medicaid programs continue to support the concept year after year cannot be ascribed to naivety, there’s gotta be something to this, 2) studies in the public domain are old studies with crude methodologies examining relatively primitive programs, while newer studies or newer programs are in-house, involve state-of-the-art consumer/physician oureach and not readily available to dubious reporters, and 3) enough with Medicare Health Support already, it was stillborn thanks to sicker patients tilting the intervention groups and Medicare strangling things by not providing timely information.

The Disease Management Care Blog offers up some additional Ver. 2.0 observations not addressed in Business Week:

1. While measures used to gauge DM, such as claims expense and hospitalizations are relatively crude, the DM industry has only just begun to coalesce around a common assessment methodology. Future reports on DM’s programs will a) hopefully use it and b) submit their findings to peer review. Pending that.....

2. No proof that DM works is not the same as proof that DM doesn’t work. And if the lack of proof is the standard by which we should judge the merits of medical care in general, what proof is there that the patient centered medical home, pay for performance or the electronic health record really saves money? Or for that matter, has anyone subjected primary care to a prospective randomized clinical trial? Before readers shake their heads at such apostasy, consider an important question: would the introduction of a primary care network into Dade Country result in lower per capita health care costs?

3. While the lack of proof is a result of the lack of positive peer reviewed research, but maybe it’s peer reviewed research's reliance on randomized clinical trials that is lacking. To quote Don Berwick in JAMA:

'...multicomponent intervention (is) essentially a process of social change. The effectiveness of these systems is sensitive to an array of influences: leadership, changing environments, details of implementation, organizational history, and much more. In such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect.'

4. As for the MHS demo, the DMCB doesn't believe any DM results from FFS Medicare is generalizable to the commerical employed populations. It's a different kind of population with a different kind of insurance benefit. What's more, the DMCB thinks it's notoriously difficult to demonstrate any savings in a FFS Medicare setting. Even the allegedly successful Medicare Coordinated Care Demo would have been a complete bust if it weren't for some statistical legerdemain that barely squeezed 1 success out of 15 times at bat. The DMCB thinks that there is too much ‘noise’ in the health care utilization of an elderly 'free-range' population with access to every health care option known to man. Modern clinical trial methodology just may not be up to the task to detect differences in an environment with a relentless 10% trend.

5. Finally, the DMCB says the real value of DM is not necessarily a function of how much it can reduce costs. Rather, its value is based on what offers for the cost. While the Business Week article alleges it adds up to billions, the cost at an individual level per member per month is comparatively modest and the benefit to the consumer is relatively high. Compared to the majority of high-cost low-value services typically covered by U.S. health insurance, DM is a bargain. The coin of the realm is NOT saving money but giving consumers their money’s worth.

(Welcome Cav of Risk Readers! There's more on this topic here)


cindilou18 said...

Al, all really great points. I'm a clinician and have been involved in DM for years, pretty much since the beginning. I no longer call it DM as I've learned people, patients, members, participants whatever you want to call them don't like to identify themselves as "diseased" I now only call it Health Management. This paradigm shift speaks to one the points in the article, engagement. It's easier to engage a participant when they hear you say you are going to help them with their "Health" Help them to feel better, get the services they need etc. Indeed, it's the most difficult part of the program. I think we as an industry need to keep working together and to keep sharing successful strategies with each other re. engagement. Trust me, it will benefit all of us, the participant who is mine today will be yours tomorrow. Just another challenge....constantly rolling enrollment! After we get adequate participation, then we can really get some great data on positive outcome! thanks for letting me share!
cindi rn,mph

Jaan Sidorov said...

Well said Cindi.

Basically, a rose by any other name smells as sweet, no?


D. Ebt said...

Yup, the description given is very informative. But it would be better if you would call it as a health management instead of disease management.