Monday, March 21, 2011

Telephonic Disease Management "Opportunity for Savings" in Body of the Article, "Does Not Save Money" in the Title?

Readers of the Disease Management Care Blog may have missed this provocatively titled article, "Telephone-Based Disease Management: Why It Does Not Save Money" that was published in January 2011 the American Journal of Managed Care. The DMCB not only didn't miss article, it quietly wrote a Letter to the Editor. It was only a few weeks ago that it learned that it had been scooped by a better letter.

The DMCB decided to bide its time.

In the original AJMC article, former Healthways researcher Dr. Motheral reviewed the early promise of telephonic disease management (borrowing from programs aimed at reducing readmissions) and the bitter disappointment that followed once the industry matured and underwent greater scrutiny. Reasons for the stumble, according to the author, were 1) numerous econometric studies that showed most preventive treatments do not reduce costs, 2) numerous econometric studies that showed most specific chronic illness care interventions do not reduce costs, 3) dawning awareness that the financial impact of increased utilization (for example, pharmacy) can exceed other program savings and 4) the non-generalizability of published positive studies versus the real world, where program content or the measured outcomes were often modified.

Yet, Dr. Motheral points to four lessons learned since then: 1) applying disease management to vulnerable patients "may provide opportunity for cost savings," 2) some commercial disease management programs work better than others, 3) face-to-face interactions are more potent than telephonic ones and 4) transparent peer reviewed studies trump enthusiastic marketing gimmickry.

The letter mentioned above has recently appeared on-line and was authored by former LifeMasters CEO and current ZOLO Consultant Christobel Selecky. In it, she points out that disease management has evolved in response to Dr. Motheral's criticisms, uses many of the approaches that have also been shown to reduce readmissions and that it's not its fault that the market is demanding costly preventive and care interventions. She also asks why no other sector of the health care industry (like physicians) has been asked stop providing services because it doesn't "save money." Rather, she argues, the future of disease management, and, by the way, health care in general, lies in generating value and continuing to build on what has been shown to work.

The AJMC Editors gave Dr. Motheral an opportunity to reply (same letter link). She notes that assessing value generally means politically thorny and intellectually complex cost effectiveness studies and that the industry, with one exception, has been remiss in showing that it can reduce readmissions. Finally, she asks, if the industry is evolving, why are employers still paying for millions of persons to get questionably effective phone calls?


So does this tempest in a disease management teacup diminish the disease management industry? The DMCB doesn't think so. Such is the nature of medical publishing, where authors vigorously debate competing approaches to care, heap scorn, score points and draw blood. In the end, issues are clarified, new areas of investigation are opened up, medical science is more precise and patients are better off.

As for the eternal debate over "saving money," it not only makes for interesting reading but great bloggery. Over its history, readers will recall that the DMCB has practically made and addressed all of Dr. Motheral's concerns, including the disconnect between prevention and savings (also by linking this article many times), the dubious value of some diabetes interventions, why disease management can work despite cost-effectiveness naysaying, the complicated nature of pharmacy in disease management, the difference between efficacy and effectiveness, the benefits from targeting vulnerable patients, combining disease management with face-to-face care, the limits of cost-effectiveness studies and the need for the industry to invest in peer-reviewed research.

As for the observation that some disease management programs work better than others, isn't that the point in a competitive marketplace? By the way, isn't that also a lesson for our faith in clunky government run demos and health care programs?

When it wrote its letter to the AJMC, the DMCB saluted Dr. Motheral for an insightful review but questioned why the editors allowed the author to use such a contentious title. After all, the body of the paper suggests costs savings are well within reach and expertly describes what the industry can do to "bend the curve."

As we know, the DMCB letter was not accepted for publication, but the question remains: why not a title worthy of a fine, balanced and supportive review, like...

"Telephone-Based Disease Management: Why It Will Save Money" or....

"Telephone-Based Disease Management: Why Cost Savings Are In Reach" or...

A DMCB favorite: "Telephone-Based Disease Management: Why The Disease Management Care Blog Has Been Correct About An Approach to Care That Can Save Tons of Money."

1 comment:

Erica J. Thiel said...

I know this may not be close to the other article but perhaps interesting?

As a patient with a long term - life long chronic illness (MPS I Hurler Scheie) I for one find Case management to be very helpful - of course it also matters a great deal on who the case manager is and their approach to the patient!