The Persistence of Disease Management: It's Not Going Away......

We're all aware of the past criticisms of "disease management." According to the critics, these for-profit vendors were in collusion with commercial insurers, relying robo-calls to blanket unsuspecting patients with dubious advice. Their claims of "outcomes" were based on flawed research that was never intended to be science; it was really intended to market their wares.  

But suppose the Disease Management Care Blog alerted you to:

1. A company that had developed a patient registry to identify at-risk patients who had not received an evidence-based care recommendation? Software created mailings to those patients that not only informed them of the recommendation but offered them a toll-free number to call if there were questions. Patients who remained non-compliant were then called by coordinators, who made three attempts to contact the patient and assist in any scheduling needs. If necessary, a nurse was available to telephonically engage patients and develop alternative care options.

If you think that sounds like typical vendor-driven telephonic disease management, you'd be right.  You'd also be describing an approach to care that was studied by Group Health Cooperative using their electronic record, medical assistants and nurses.  When it was applied to colon cancer screening, a randomized study revealed each additional level of support progressively resulted in statistically significant screening rates.

Or how about.......

2. A major insurer that decided to use its claims data to identify its own "best practices" without waiting for any published evidence-based studies?  Since "strict experimental conditions cannot always be met," shortcuts like time-series analyses" and "propensity score approaches" will be used to "blur" the lines between feedback and evaluation, as well as the lines between provider and insurer?

If you think that sounds like an commercial insurer muscling into health care delivery while using quasi-experimental research shortcuts, you'd be right.  You'd also be describing how Medicare's Innovation Center is borrowing from the disease management industry's approach.  It's all here.

Lastly, there's......

3. A major insurer that decided to NOT to pay primary care sites enough fee-for-service or capitation, preventing them from hiring nurses who could provide coordinated care.  The insurer instead hired its own nurses and "embedded" them in the primary care sites while linking additional monthly payments of approximately $5 to pay-for-performance metrics.

If you think that sounds like a step away from the usual Patient Centered Medical Home, you'd be wrong.  In this instance, having the embedded nurses did not get in the way of the sites achieving PPC-PCMH recognition. What's more, compared to usual care in a prospective randomized study that was underwritten by the medical-home fans at the Commonwealth Fund, the embedded nurse approach resulted in better hypertension care, breast cancer screening and fewer emergency room visits.

Alas, disease management: to paraphrase The Bard, a rose still smells as sweet by any other name, especially if it's used by Group Health, CMS and the Commonwealth Fund.

Europe Likes U.S. Disease Management

Listen to public radio, read the national newspapers, surf the standard cable channels or listen to the mainstream commentariat and the message is the same: if only the U.S. would import the best of European-style health care, life-expectancy rates would increase, health care costs would decline and physicians like the Disease Management Care Blog would bask in the benevolent and enlightened management of the U.S. Department of Health and Human Services.

As the DMCB has pointed out before, comparative national data are not a slam-dunk, untangling unique non-medical cultural and economic impacts on population the U.S. is complicated and the U.S. in some instances, is getting its money's worth.  What's more, rising health care costs are a global phenomenon and there is no evidence that dropping European-style health care on the U.S. will blunt its overall cost inflation. As for the enlightened benevolence of HHS, just remember that their Board of Directors is Congress and that Taxmageddon promises that the SGR fix won't be pretty.

Yet, while DMCB readers may have a reason to be skeptical about the wisdom of of europhilism, what about the possibility that our beret-wearing, cobblestone-hopping, Audi-driving and cafe-sipping cousins across the Atlantic admire the U.S. system?  Impossible you say?

Think again.  The DMCB has personally been to Europe to share the good news about U.S. approaches to disease and management. The Care Continuum Alliance has an impressive international presence made up of organizations using elements of  disease management and population-based care. Many of the vendors sell millions of dollars' worth of services in Europe. 

To drive the point home, here's recent and telling opening quote from a internationally published paper in Health Expectations on the topic of disease management:

Inspired by American examples, several European countries are now developing disease management programmes (DMPs) to improve the quality of care for patients with chronic diseases.

More On The "Death" Of Disease Management

At the email prodding of several colleagues, the Disease Management Care Blog next turns its attention to a blog posting by Archell Georgiou MD provocatively titled "The Death Of Disease Management (Finally!).  The Archelle on Health Blog contrasts the industry's early promises of evidence-based medicine plus patient self-care with the bitter fruits of non-existent savings, the disappointing Medicare Health Support (MHS) demo and a just-published anti-disease management New England Journal article. 

Using that last Journal article as the final word, Dr. Georgiou provides her readers with a graveside eulogy of what went wrong:

1. The NCQA promoted an "enroll and counsel all patients at risk" approach, when what was really needed was a focus on the patients at greatest risk.

2. The disease management industry relied on gimmicky marketing instead of reducing costs, and

3. Inflexible adherence to evidence-based medicine failed to account for individual patient circumstances.

Enter Al Lewis of the Disease Management Purchasing Consortium with a rebuttal, but, um, sort of.  Al points out that the DM industry still clings to life and, even worse, uses spurious financials.  Yet, thanks to ICD-10, inclusion of labs in predictive modeling, lower program costs, physician involvement and the marvelous insights of his soon-to-be-published book, he confidently predicts that the DM vendors will emerge from what is better described as a near-death experience.

Where to start?

Medicare Health Support's Lessons

That New England Journal article used by Dr. Georgiou to  nail DM's coffin was a really retread of Medicare Health Support's (MSH) failings.  Look deeper and what MHS really demonstrates is CMS' ineptness in demo design, program support and data interpretation.  Toss in this CBO Report and it's clear that the issue isn't whether DM "works" in in FFS Medicare, but that the administrators running FFS Medicare don't know how to implement DM. 

Disease Management Is In Use In Most Commercial Settings

CMS' bumbling stands in contrast the long term and continued reliance by commercial insurers on disease management in the commercial and self-insured sectors.  While nattering nabobs may suggest that the commercial sector isn't paying attention to the "evidence" of studies like MHS, a cursory search of the published literature can find studies like this, this, this, this and this that suggest that the commercial sector knows what it's doing and that patients and their premiums are better off for it.

Disease Management Ver. 1.0 Deserved To Die, But Didn't.  It Changed

Archelle On Health has it only partially right. When industry's own studies proved that a) an all-patient approach didn't work, b) it had to get serious about documenting outcomes and c) patients had to be "engaged" on their own terms, it didn't crawl into a hole and die.  It changed to what the DMCB has characterized in past postings as "disease management Ver. 2.0," otherwise known as "population health."

And What About Al Lewis' Insights?

The DMCB agrees with four out of five.  If his new book is anything like his last one (by the way, it included the DMCB as an author), make that five out of five.

But Wait, There's More!

In the original "Death" post, Dr. Georgiou points to six innovations that promise to further shake up the landscape of population health: social networking, gaming, remote biometric monitoring, wireless health management apps and "passive" environmental changes that lead denizens to lead more healthy lives.  The DMCB says she's right and finds the topic endlessly fascinating.  While the population health and disease management industry is using monitoring and social media, it remains to be seen how it will embrace the other innovations. 

That being said, the DMCB hopes that Medicare doesn't run any demos on any innovations like gaming, apps or environmental changes, lest future bloggers end up pronouncing their death too.

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