Disease Management in Medicare Pilots by Bradleystephens


									                                 Health/Care Brief #2:
                                    Disease Management
                   .02               In Medicare Pilots

                                                       Not Surprising:
                                          Standalone DM Programs in Medicare Pilots
                                                   Produce Minimal Results
                          The January/February issue of Health Affairs reported on the results of a decade’s worth of piloting
                         Disease Management programs within Medicare. In this Health/Care Brief, we’ve highlighted the key
                         findings that emerged from this pilot, their implications going forward, and how Coordinated
                         Health/Care addresses the challenges identified by this pilot.
  After 10 years, not
  one of the 35 DM       The DM programs for the Medicare demonstration projects were similar to those offered in
                         the commercial space, in that they were “bolted on” to an existing health plan structure – in
   programs piloted      this case, Medicare. The companies in the pilots had to use predictive tools to identify and
   within Medicare       stratify patients, and employ a variety of techniques to contact such patients and then further
                         engage them in dialogue about self-care related to their chronic condition. While there are
    demonstrated         differences in the Medicare population, the experience of these pilots is instructive and the
                         challenges faced parallel those in the commercial space.
  savings in terms of
   claims reduction.     After 10 years, not one of the 35 DM programs piloted with Medicare demonstrated savings
                         in terms of claims reduction. At the end of the study period, three had evidence of quality
                         improvement at or near budget neutrality, and four were close to covering their fees; but 15
                         actually increased cost by 11%. This is consistent with findings in the commercial market
                         where a 2008 study by the Rand Corporation showed no study indicating evidence of DM
                         programs reducing total claim cost for employers.

                         There are significant challenges in the way DM programs are typically “bolted on” to the
                         plan and not integrated in the mainstream relationship with health plan members. The
                         Coordinated Health/Care view is that while disease management activities work, disease
                         management programs generally don’t. Coordinated Health/Care incorporates DM activities
                         into the program, but maintains a much more robust and pervasive relationship with the
                         members that allows more impact upon utilization and cost trend.

                         Results reveal expectations went unmet – for predictable reasons
                         Within these pilot programs, DM was expected to increase compliance with evidence-based
                         care, improve provider and patient satisfaction, and produce financial savings net of fees.
                         The results indicate that none of this was achieved. There are predictable reasons for such
                         results, several of which are addressed by the Coordinated Health/Care program:

                         •   Periodic contact only accidentally identified acute care needs. The studies noted with
                             surprise the low level of member contact by the DM companies – once every two to three
                             months – not enough to detect acute problems as they emerged. But, the study noted
                             that even programs in which there was DM contact three to five times/month failed to
                             identify such opportunities, noting that “such infrequent contact can only
  For more information       serendipitously identify early symptoms of acute exacerbations.” We think this has less
   P- 1.800.257.2038         to do with the frequency of contact and more to do with limited scope of inquiry during
   F- 1.800.347.9660
www.Quantum-Health.com       contact. Conversations related to self-care often failed to identify any other care
                             management opportunities.
                         •   80%-90% of hospital admissions were for reasons other than the condition being
                             managed – i.e., unrelated to the chronic condition that was the focus of the DM service.
                             Again, this highlights that traditional DM is not really integrated into the patient’s day-
                             to-day healthcare needs and is therefore unable to impact utilization when it is happening.

                         •   Not enough provider support. What providers mostly need is coordination of services
                             among the multiple providers chronic patients use. Focused only on self-care, DM has
                             no impact on the services that would be helpful to providers – DM simply isn’t involved
                             in the day-to-day care these members need.

                         •   Patients had already learned to adapt to their condition and were not motivated to
                             engage. Pragmatic research shows that it is difficult to get people in their middle age to
                             change – especially patients who’ve had a disease for a while. Studies found that patients
    “…infrequent             had learned to accommodate their disease and didn’t see any benefit to changing
                             behavior. This was the underlying reason that activity and adherence rates did not
  contact can only           change among the population with DM services.
                         Implications for effective Disease Management
    identify early       The clear implications of these findings, consistent with our learning through ten years of
                         operating the Coordinated Health/Care program, are:
 symptoms of acute
                         •   To affect cost and utilization, DM must be integrated into, and part of, the day-to-day
   exacerbations.”           healthcare administrative functions of the health plan – this is where the patient lives.

                         •   Support must be given to provider offices to assist with coordination among multiple
                             providers and to facilitate interventions when patients’ needs intensify – basically,
                             effective care management acts as an extension of the physician’s office.

                         •   Members must have multiple channels through which to connect with care coordinators
                             when experiencing acute healthcare needs, since it is only by chance that outbound
                             contact will occur at precisely the right time to identify such situations.

                         •   Members must have benefit incentives to create urgency and motivation for them to
                             engage in improved self-care. The benefits discussion must be part of, and integrated
                             with, all care discussions. Bolted-on DM cannot accomplish this.

                              Comparison of “old model” and Coordinated Health/Care™ “intercept” model for
                                 identifying patients for Disease Management intervention and assistance

                                  TRADITIONAL DM/WELLNESS                             CHC “INTERCEPT” MODEL
                             •    > $200 per connection, low ROI              •   61% of members touched per year
                             •    105-day delay, diagnosis to contact         •   84% of households contacted annually
                             •    < 0.5 touches per member per year           •   2 or 3 touches per member per year
                             •    1%-3% total members contacted               •   92% of the 11% with chronic conditions

                             Traditional DM and wellness models rely on        Coordinated Health/Care’s Single-Point Patient
                             mining claims data in the hope of reaching the   Service and robust system of notifications and
                             patients who need DM assistance when they        pre-certifications “intercept” members at self-
  For more information          happen to be receptive to intervention.         identified moments of need, when they are
   P- 1.800.257.2038                                                                      reachable and teachable.
   F- 1.800.347.9660

To top