Thursday, September 23, 2010

A Prospective Randomized Trial of Disease Management in the Latest New England Journal Shows It Saves Money

In this prior post, the Disease Management Care Blog defended and defined disease management as the use of a package of mutually supportive interventions to improve quality and/or mitigate the insurance risk of a population defined by the presence of a chronic condition. It predicted that, thanks to greater sophistication in both the targeting (for patients that are likely to benefit) and the provision (behaviorally-based engagement, dealing with barriers, motivational coaching) of the interventions, that the "disease management" brand would regain its luster. All that was needed was for disease management industry to act a little less like a business and adopt medicine's tradition of rigorous scientific inquiry with sharing of its evolving knowledge to advance the health care for everyone.

Well, the industry is getting there and in the prestigious, staid and sometimes hostile New England Journal of Medicine, no less. Check out this important study by David Wennberg, Amy Marr, Lance Lang, Stephen O'Malley and George Bennett that was just published in the Sept 23 issue, titled "A Randomized Trial of a Telephone Care-Management Strategy."

Good thing you read the DMCB. You can, once again, quickly familiarize yourself with the study's, bottom line and sagely discuss the results with colleagues, enemies, audience members, bosses, bosses' bosses and, if you have the President's ear, with our nation's Chief Executive. Heaven knows he needs all the help he can get.

Two regional insurers that contracted with Health Dialog agreed to compare two telephonically based care management approaches: one was "usual" and the other was "enhanced." The latter enhanced used a variety of predictive modeling techniques (that also importantly included the risk of surgery for a preference sensitive condition) with lower cut-off points for risk. This, in turn, resulted in greater numbers of persons being targeted. The modeling also allowed Health Dialog to focus on patients who were neither too sick or too well to benefit from care management. Once patients in the usual or enhanced groups were contacted, the telephony care management content was the same.

Within each of the two health plans, there was an HMO, POS and PPO. To neutralize the effect of the varying insurance benefit, enrollees were randomized within each benefit plan. The household member at highest predicted financial risk determined assignment for all the household members. Persons had to opt out. They also weren't aware of the assignment.

There were a total of 215,006 eligible persons, of which 34,629 were excluded because of missing enrollment information (which the DMCB knows is not uncommon). An additional 667 were excluded because of high cost conditions like HIV or end stage renal disease. An additional 5590 persons lost or changed their plan coverage while the study was being set up, resulting in 174,120 final subjects. This included 7000 enrollees over age 65 with concurrent Medicare coverage.

All the targeted persons received recruitment outbound mail, interactive voice response calls and live calls by Health Dialog personnel, but the enhanced group got five attempts vs. three in the usual support group. Once patients were enrolled, the care management involved the state-of-the-art coaching by a spectrum of non-physicians. This involved motivational couseling aimed at behavioral changes and increasing shared decision making in interactions with physicians, all supplemented with a variety of media aids. Coaching was also tailored for the burden of the chronic conditions as well as the likelihood of surgery for the preference sensitive condition. The authors estimated that the total program cost for the insurers for the enhanced program amounted to $2 per member per month (PMPM).

Because the study was prospectively randomized, the usual and enhanced groups were demographically similar (for example, the average age was around 37 years with a typical baseline commercial per member per month cost of around $170), the burden of chronic conditions was the same (about 10% in both groups had at least one). The difference was that 26% of the enhanced group was targeted for outreach vs. 7.8% in the usual care group. Ultimately 10.4% of the subjects in the enhanced group ended up getting coached vs. 3.7% in the usual group.

Over the year of study, compared to the usual care group, there was a statistically significant medical claims savings of $8.48 PMPM in the enhanced group. This represented a 4.4% reduction in claims expense. Pharmacy costs went UP in the enhanced group by $0.52. When everything was added up, the overall expenditures decreased by a net of $6 PMPM or 3.6%, including the $2 PMPM cost of the program. Much of the savings appeared to result from fewer hospitalizations as well as an 11.5% reduction in admissions for preference sensitive conditions.

Well done, says the DMCB. There aren't many options for addressing our nation's rising health care costs that doesn't involve more government, more barriers or more bureaucracy. One of those options, according to this study, is disease management, otherwise often known as telephone care-management.

Note that this study didn't compare care management vs. no management. Instead, the DMCB thinks that argument that the intervention worked is based on a correlation with exposure. In other words, if more persons get the intervention and more costs are saved, it's safe to assume the intervention worked. That's what happened here.

To Health Dialog's advantage, the study also showed that its version of disease management (with a focus on coaching patients with preference sensitive conditions, which you can read about here) works better than its "usual" competition. That's called a two-fer. The advantage is that Health Dialog can have its cake and eat it too. The disadvantage is that the DMCB can't tell how much of the study's success was due to recruiting more patients, targeting the right patients or using Health Dialog's special emphasis on preference sensitive conditions. It might be all of the above.

Note that this study also addressed the canard that "disease management" is limited by focusing solely on one disease at a time, leading to the "balkanization" of health care. In this study, the telephony was tailored to the patients' total disease burden.

It's also interesting to note that recruiting only 10% of patients of a population at risk translates into real savings. In other words, not every patient at risk needs to be called to make a difference.

The DMCB also suggests that the study's credibility was increased by the observation that pharmacy costs increased. The DMCB has personally witnessed that in other programs and it would be an expected outcome of aggressive patient coaching.

As Journal readers would expect, the authors did a good job of pointing out the caveats about generalizing this study to all patients everywhere. This study was limited to commercial patients and there is no guarantee that this would work in fee-for-service Medicare. However, that didn't stop the authors from estimating that about half of the observed savings went to the U.S. Treasury thanks to lower costs among the 7000 Medicare participants.

The only downside to this study is that there is little information on the accompanying quality of care or about the possibility that the interventions somehow led to denials of needed care. The DMCB doubts this happened. This is a huge study with a very large database, so it's possible that there were be follow-on studies providing a clearer picture of what happened. Let's hope so.

This study is adding to a growing body of research that points to the quality and cost-saving merits of disease management. Right now, the DMCB doesn't have the time to do it, but it suspects there's another meta-analysis that's needed. The results are likely to be different.

Hopefully, as we continue to improve health reform, the important potential of disease management interventions like this will get the attention it deserves.

1 comment:

Sam said...

The results of the study may quiten the care management critics and is a good reminder that DM works. I agree that QoL aspects should be evaluated in the near future.