Wednesday, July 8, 2009

Prognostications on the Future of Disease & Population-Base Care Management - From a BrightTALK Webinar

Today the Disease Management Care Blog gave a BrightTALK webcast on 'The Future of Disease and Care Management for the Chronically Ill.' While the 45 minute PowerPoint presentation and audio are available on line, your DMCB is delighted to provide a short summary of the DMCB's admittedly optimistic prognostications. They may come true, assuming coming U.S. health reform doesn't completely gut the industry's passion for 'Skunk Works' style innovation.

Outside of the commercial markets, an alternative way to think of these hunches are as domains to assess the real sophistication of the various coming health reform proposals. Cover the medical home? (Yawn). Promote use of electronic records (Tsk tsk). Insure everyone? (Easy, if all you have is money and little imagination). If the wunderkids among the Congressional staffers and White House war room denizens are able to accomodate these following concepts as they hammer out their health reform proposals, then we'll be really getting somewhere:

Convergence of Disease Management & the Medical Home: While there are significant historical, economic and cultural barriers to this, advocates of both approaches have much more in common than is widely appreciated. While that alone may not be enough to combine sophisticated remote telephony with high touch primary care-based care management, the DMCB is an optimist. While this didn't come up during the webcast, it thinks that health reform that promotes versions of accountable care organizations or ACOs (which has challenges) may be the perfect venue for DM and MH collaboration - if it also gets engineered into the legislative language.

Emphasis on Demand Management: Other terms for this include consumerism and patient centered medical care, but the bottom line that that the core of any population-based care management program will consist of behavioral interventions that enable and assist greater self-care. This means the core will not be the electronic record, physician payment reform or any other number of policy notions. Rather, these and all the other elements will need to play a supportive role to meaningful, industrial-level health consumer engagement.

It's a Soup, not a Soufflé: Who says cookbook medicine is bad? It isn't if there is room for the kind of creativity that is allowed by cooking up some soup. Wrapping all the ingredients around demand management will require considerable flexibility based on local patient culture as well as the type and availability of other local care resources. The difference between Buloxi and the Bronx will stymie one-size-fits-all policy and reimbursement models, and Federal inflexibility represents the greatest threat to meaningful population-based healthcare.

The 'Build or Buy' Sine Wave Will Continue: Those of us with backgrounds in health insurance eventually learn to live with the routine: initiate an in-house program to deal with some challenge in the enrolled population, determine years later that it can be done more effectively as a carve out, then, with a change in leadership or a problem in the medical loss ratio, determine that it can be better dealt with by initiating an in-house program...... That isn't necessarily bad, but it does speak to the need for local systems to contract then construct then contract then construct care programs based on shifting circumstances.

Single Platform: The growing availability of truly robust and modular informatics solutions means that computerized systems that undergird underwriting, disease management, utilization management, case management and the electronic/personal health record will enable insurers/systems to have a single 'view' of their patient population. What's more, knowing how to promote wellness among persons with chronic illness to manage utilization (for example) will be a growing competitive advantage. There will no longer be an excuse to not tie it all together.

The Rise of Nimble Research: By the time the Comparative Effectiveness Research academics begin to submit their manuscripts to journals that few read and even fewer care about, the care management industry will increasingly use quasi-experimental inquiry designs that answer the important questions with reasonable assurance. It remains to be seen whether they'll bother with the academic journals or rely on some other venue to share their findings (like blogs).

MORE Chronic Conditions: That's right: migraine, chronic pain conditions and metabolic syndrome are some of the current leading candidates. Plus, an off topic comment: the idea that 'disease management' companies are limited by nurse coaches that 'only' deal with 'one' condition at a time, leading to the inefficient balkanization of care, is a tiresome canard. Expect the same nurses to be cross trained in new conditions. What's more, expect screening for conditions (like migraine) start with the 'captive' patients in the old disease management populations. One other point: pharmacy benefit managers are starting to find patients for disease management programs.

Automation, automation, automation: The rise of scalable and fully automated remote monitoring systems with branching logic, computer controlled speech and integration with electronic records is reaching the tipping point. This will drive down the cost of disease management programs, because fewer full time equivalents will be needed. The DMCB does not expect a wholesale reduction in force over this, because it thinks successful DM remains ultimately a high-touch value proposition.

Say Hello to the Cell Phone: If you think persons are going to be managing their chronic conditions with some lap top or home desk top on some password protected website, think again. The cell phone can hold lots of the necessary information (medication list) and access the rest (electronic versions of all past imaging studies, like x-rays) from some cloud server somewhere. Care management organizations that learn to integrate their information systems with the DMCB's Blackberry will win.

Coda: This isn't the first time the DMCB has been soothsaying. So far, it looks like the first batch of predictions is holding up.

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