Tuesday, June 14, 2011

Is Population-Based Care and Disease Management Fair? Worse, Is It (Gasp!) Socialist?

Oncle Karl would be proud?
The Disease Management Care Blog is currently blogcasting from Newark International Airport where, along with thousands of other travelers, its best laid plans are being humbled by the sullen and fickle weather gods.  It's on its way home after being a speaker at the Florida Health Care Coalition Care Management Summit

The DMCB was once again reminded of just how savvy the business community is about the twin health care challenges of cost and quality.  That's not only because they're eroding their profit margins, but because these employers are highly committed to the wellbeing of their work force.  We in the health care industry ignore their insights and advice at our peril.  

The long airport sojourn has given it an opportunity to think about an excellent question that came up during the post-talk Q'nA:

What is your response to the criticism that persons with chronic illness who are already working hard to care for themselves may not have the same access to services and incentives as patients who are less engaged in their self care?

As us population-based care management'ites may recall, the more modern versions of our approach to care segments populations using two key criteria:

1) high "risk" (or need), and

2) high engagement potential (or readiness to change). 

Patients with a pattern or a profile that suggests a high likelihood of future avoidable hospitalizations or complications are good candidates for intervention.  Patients who express a willingness to assume greater responsibility for self-care are good candidates for intervention.  Patients who exhibit both are ideal candidates for the interventions.  This includes one-on-one coaching, telephonic support and, depending on the circumstances, various incentives, home-based telemonitoring and expedited care.

The DMCB suggests this works because targeting complex care management at the patients most likely to benefit not only preserves precious resources and has a return on investment, it is more likely to achieve disease control.  What's more, the early versions of "disease management" that tried to "call everyone" generally failed.

Despite its merits, the questioner correctly pointed out that this "Ver 2.0" approach could be criticized for effectively shutting out other patients who may not "make the cut" because they already minimized their risk through their own grit and determination.  Yet, these patients could also benefit from the "boost" of participating in a care management program and many might welcome the chance to reduce their risk even lower. What's more, its "from each according to ability and to each according to need" approach strikes the mostly conservative DMCB as a curiously socialist posture for a health care program. Last but not least, accepted social policy not only strives to "pool" insurance risk but pool the social benefits that flow from that.

The DMCB response?  Inadequate at the time of the presentation and it will continue to ponder this, preferably soon and on the other side of an airport security check point. 

Some initial thoughts:

1. To the DMCB's knowledge, the issue hasn't really come up in the market-place to any significant degree.  While being "shut out" is a theoretical worry, patients in the" real" world who are already doing a good job of self-care may be less concerned and the vast majority may think of this as a non-issue.

2.  While lack of access could paint a picture of social injustice, all patients ultimately win if there is an impact on health care costs.  This assumes, of course, that the health care system savings translates into lower prices.  Not a strong argument.

3. One potential fix is to prominently advertise the program and agree to all patient requests for entry into the care management program.  In other words, in addition to high risk and high readiness, high interest is also a criterion for entry.

4. Financial incentives linked to participation in disease or care management programs may be more complicated, says the DMCB.  It's no lawyer, but beware of potential limits on how that can be used.

5. Last but not least, this is an area that may benefit from having a patient advisory committee, an appointed advocate or an ombudsman to help steer policy and maintain fairness from the consumers' point of view.

The DMCB welcomes input from readers on the topic.

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