Tuesday, January 3, 2012

Should Health Insurer Coverage Be Conditional On Participation In Disease Management?

Standing between patients
and outcomes?
The unsophisticated Disease Management Care Blog used to think the answer was a simple yes. 

Its rationale was twofold:

1. The patient impact of the medical and pharmacy benefit, i.e., medications and other treatments, will be greater if there's a link to concurrent care management services that promote self care and increase doctor-patient engagement, and

2. The gateway to accessing the medications and treatments could be used to incent enrollment in care management programs which, depending on the circumstances, increase quality and lower costs.

Both factors undoubtedly underlie the decision of many insurers to combine disease management and coverage of certain services.  For example:

Many Medicaid programs won't cover tobacco cessation medications unless the patient is participating in "counseling services."  That's because much of the original research on the drugs showed they work if they are linked to concurrent behavioral support.  By the way, the same is true when it comes to drugs for the treatment of obesity (page 53), which showed up in this coverage document.

In addition, consider the example of "external insulin pumps."  These are battery powered, small and discreetly wearable devices that provide a highly tailored course of insulin to persons with diabetes.  They are are also complex and expensive, which is why many commercial health insurers rely on guidelines that require participation in a diabetes program before they'll be approved.

There are exceptions to the rule.  For example, while asthma treatment guidelines (page 60) recommend 'instruction, demonstrations and frequent reviews' along with the prescription of peak flow meters, coverage of these devices is not conditional on participation in an education program.

Upon further reflection, however, it occurred to the DMCB that having to enroll in disease management - whatever its merits - could be viewed by patients as a barrier which could, in turn, paradoxically reduce medication possession ratios, participation in tobacco cessation programs or use of insulin pumps.

In mulling this over, the DMCB turned to the topic of Value Based Insurance Designs. While VBID can be defined as the explicit setting of patient out-of-pocket-cost (such as co-pays or co-insurance) to the underlying value of any medical service,the DMCB thinks it can be broadened to include the removal of any barriers that stand between the patient and high value services.  The highly regarded University of Michigan's Center for Value-Based Insurance Design, in this excellent review, doesn't think of disease management as a barrier but as an incentive.

Incentive or not, the good news is that it's possible to combine VBID and disease management that together achieve outcomes that are better than either one alone.  Unfortunately, the DMCB fears those outcomes are limited to patients willing to enter the programs in the first place: there may be a larger unseen population outside the disease management intervention who aren't included because they don't want the hassle.  In other words, good outcomes for a few known participants doesn't make up for the potentially bad outcomes for the many non-participants.

If any readers have an answer, the DMCB would appreciate hearing from you.  In the meantime, the DMCB cautions that the population health management suppliers need to be aware of the downsides of linking insurance coverage to their services.  They also need to do everything they can to avoid being viewed by patients as a barrier.

Image from Wikipedia


Big Chewy Pretzels said...

My comment was getting lengthy so I cut it back. Hopefully it still makes sense.

To me, the way to achieve this is by making DM a core component of primary care and eliminating the opt-in or out issue. The intensity of DM protocols are based on what the patient and provider jointly determine is best.

This is a situation where partial efforts, such as an insurance company demanding DM on a portion of the population or paying a bit extra to primary care for some additional services, fail. Success requires jumping in with two feet and aligning the interests of the employer, the patients, and the primary care providers.

I'd argue that the payment model needs to be aligned so that PCP is contracted directly with populations (e.g. self-insured employers) to avoid the issue of trying to get PCPs to perform DM services on a small sliver of the population.

Jaan Sidorov said...

From HealthPoints:

The questions raised here are important and well put. Our company management team previously ran the care and disease management program at one of the largest health insurance companies in the country. One (of the many) challenges we found with the programs provided there - which limited the program impact to a narrow slice (of already motivated!) individuals - was the Opt-In structure. In this case, a large portion of the telephone nursing staff’s job was “selling” the program to health plan members. Despite much time and effort, the sell rate (and thus program enrollment rate) was still very low. Experiences of the team piloting opt-out services captured a much higher portion of the population.

This one step of moving from an opt-in to opt-out structure won’t solve all the issues raised here, but was found to be an effective way to increase program reach into the population.

Jaan Sidorov said...

Big Chewy Pretzels makes a good point: the physician needs to be involved in the referral process and can work with the patient to make it happen. I'd agree but point out that in the real world, despite extensive outreach to physicians with lots of buy-in, that the otherwise supportive docs generally neglect to refer. That can be overcome by P4P, which I've referred to in a prior lifetime, as a patient referral "bounty."

And speaking of the real world, HealthPoints' description is especially telling.

Anonymous said...

I have thought of the same, however, with readmissions.

If a patient is offered an evidence based intervention to reduce their chances of returning to the ER in <30 days, and they refuse it--after an informed discussion, is the hospital liable?

Patient has capacity, but bad judgement. Its going to occur.

relevant citation: