The DMCB also got some great feedback. The most insightful was from an email by Bob Stone of Healthways, which is (mostly) copied below:
I would be comfortable with that conclusion if it was caveated to reflect the growing understanding that they’re the group to target for short-term improvement and return. The evidence is also abundantly clear, however, that next year’s middle and high risk patients are most likely to come from the lower risk profile groups. Most studies – including the ones you cite – don’t run long enough to capture that dynamic.
Exactly, says the DMCB. The "logic of the middle" only works in economic environments where care/disease management contracts with their performance guarantees extend from one fiscal year to another. As one seasoned nurse executive taught the DMCB, the irony of that approach is that after three years or so, it's typical for the "return on investment" from these programs to trail off. Risk can be managed within a year, but it seems insurance beneficiaries have a habit of living year after year after year....
Bob Stone takes the irony one step further. He points out that the disease management programs that use this "middle" business model are ultimately the product of a myopic "sickness" care system that fails to deliver what patients really want and what society really needs: better wellness and prevention programs that function many years further upstream. Until America achieves that, we're going to spend precious treasure figuring out how to spend less of it.