Health/Care Brief #2:
.02 In Medicare Pilots
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
www.Quantum-Health.com contact. Conversations related to self-care often failed to identify any other care
• 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.