In 1995, Dr. Steven Rosenberg published an article in the New England Journal of Medicine (NEJM) that fueled the start of an industry. In a randomized, controlled trial, he showed that an investing in proactive disease management (DM) activities could decrease the cost and improve the quality of life for patients with congestive heart failure.
The premise of disease management seemed intuitive:
· Systematically assure that evidence-based medicine is applied.
· Educate and empower patients to practice self-care.
· Intensely manage the sickest 5-10% of the patients driving 80% of the costs.
Healthplans, employers and other payers (and I) jumped on the bandwagon hoping that these programs would be a consumer-friendly silver bullet to escalating health care costs.
Cardiac Solutions, Matria, LifeMasters and American Healthways, among others, became household names. In addition, business opportunities abounded:
· Disease Management Association of America was founded in 1999.
· NCQA developed an DM accreditation program in 2002.
· Data analytics companies developed predictive modeling tools to better identify the highest risk patients.
· Employee benefits consultants promoted the “new new thing” for cost control.
But, behind the scenes, there was a lot of hand-wringing. On the eve of a major Disease Management conference, circa 2004, I remember sitting in the bar of an Orlando hotel having cocktails with DM gurus who who’d nabbed the coveted keynote speaker spots at this major forum. The Medicare Modernization Act of 2003 had just passed, and CMS had a mandate to test the disease management model in Medicare fee-for-service beneficiaries. I was shocked when my industry colleagues admitted that this $20 billion industry would only last as long as it would take for the pilots programs to be completed and CMS to analyze the results.
In the mean time…double-digit healthcare cost inflation fueled employers demand for a wide array of condition-specific programs as a cost reduction strategy. According to Mercer Consulting, in 2010, 73% of employers offered disease management programs even though consistent, reproducible evidence of a positive ROI is still lacking.
It’s been seven long years since that Orlando meeting…and the time has come when will disease management may finally…finally…. fizzle and die.
The CMS demonstration programs started between August 2005 and January 2006 and preliminary results reported in 2008 concluded that "Results to date indicate limited success in achieving Medicare cost savings or reducing acute care utilization." The individual programs, all using nurse-based call centers, ended between December 2006 and August 2008, and the definitive results were published in NEJM in November 2011. In summary:
- Only 2 of 15 programs resulted in reduced hospital admissions. None generated net savings.
- There were only 14 significant improvements in process-of-care measures out of 40 comparisons.
- These modest improvements came at substantial cost to the Medicare program in fees paid to the disease management companies ($400 million), with “no demonstrable savings in Medicare expenditures.”
So, why did this intuitive approach to managing disease fail?
In my opinion, there have been 3 critical missteps in the evolution of this industry:
1) NCQA Accreditation Standards: NCQA’s health plan accreditation standards require that DM programs be population-based—in other words, that ALL individuals with a condition be eligible for participation--not just those at highest risk who are most likely to benefit clinically and financially. Healthplans and vendors complied to achieve the marketing value of the NCQA gold seal of approval. Employers bought into this approach in the spirit of “prevention.” However, this peanut butter approach allocates time and money to individuals who are so low risk that there is little opportunity for clinically meaningful improvement that translates into financial savings.
2) Toys and Trinkets: From glossy brochures to felt puppets to refrigerator magnets, DM companies have differentiated themselves with collateral materials that have sales appeal but have little impact on improving care or decreasing utilization. At the same time, all these all of these items inflate program costs and erode ROI. At the end of the day, DM that does not achieve a net savings is not successful.
3) Over-reliance on Evidence-Based Medicine: Yes, EBM is the holy grail. However, the sole reliance on these standards in disease management interventions does not actually "manage disease” since avoidable costs are frequently due to subtle opportunities and gaps in care that exist as a result of multiple co-morbidities. For example: A patient in a diabetes DM program may also have rheumatoid arthritis. If the patient’s hand/joint pain is not well managed, it is unlikely that she will be able to comply with manually operating a glucometer to check her blood sugars. Unfortunately, the critical thinking required to truly coordinate care is difficult to systematically build into program design....therefore, too often, its absent.
So, if disease management doesn’t work, what does?
This month, hundreds of health care entities will be submitting proposals to CMS to get a piece of the $1 billion funding available through the Health Care Innovation Challenge. As CMS grants between $1 M and $30 M to various projects, let’s hope that they fund initiatives that reflect fresh, not "same old, same old" thinking for improving health and decreasing cost.
Technologies and platforms that are relatively low cost, scalable and seem the most promising are those that leverage:
1) Social networking—Condition-specific communities of patients continue to proliferate and the user-generated content from “people just like me” is having a positive impact on compliance, self-care, and quality of life.
2) Gaming: Health gaming is extending far beyond Wii Fit. Game developers are designing increasing numbers of consumer-oriented applications that address prevention, healthy lifestyles and disease self-management.
3) Remote monitoring: Biometric and ambient activity sensors offer clinicians and caregivers 24/7 insight to a person’s clinical status so that care can be delivered when it’s needed rather than when it’s scheduled.
4) Mobile/wireless health management applications: In addition to consumer focused health management apps, mobile and wireless access to patient medical information accelerates how physicians make critical diagnostic decisions and can prevent delays in care.
5) Environmental solutions: Innovative companies are poised to transform health care with disruptive products and systems that rely on design thinking--solutions that make it easy to be healthy, passively and continuously support better health, and don't rely on individual behavior change.
Proposals are due January 27, 2012. Awards will be announced in March. Results won’t be in for 3 years.
In the mean time, employers looking for immediate health care cost savings can save $2-5 per member per month in fees by terminating their disease management programs.
Disease Management: RIP
Disease Management: RIP
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hmmm...
ReplyDeleteReports of the death of disease management may be greatly exaggerated. There are programs that work, but many that don't. A lot of over-measuring and over-promising has severely damaged the credibility of the field. But others work modestly well enough to pay for themselves and then some.
Don't put too much stock in mHealth. The numbers don't add up there either, for the most part. Very few programs relying on voluntary compliance with no big economic incentives move the needle.
And just for the record for people keeping score at home, that article had very little to do with the growth spurt. This is the first I've heard of it. The growth was caused by Humana's dramatic, high-profile adoption of multiple programs across multiple markets (at my urging). Others soon followed.
Al,
DeleteYou definitely get credit for spearheading alot of the growth in this industry. Now we all know better. Your caution around mHealth is valid...and it, too needs to be measured. But at least it's a cheaper investment so that a smaller clinical impact has an opportunity to translate into a positive financial return.
It reminds me of cigarette black box warnings and smoking cessation classes, both with little to no efficacy relative to public and workplace bans on smoking, which really moved the dial.
ReplyDeleteThere's no question that creating social networks of patients with chronic diseases can have lasting impact on medication and treatment compliance. The problem with institutionalized DM was expecting the same interventions to work for a diverse population with a wide range needs, motivations and barriers to change.
ReplyDeleteDon't discount smart, adaptive population health programs. Employer such as Safeway Stores have created a culture of healthcare consumerism which requires active participation rather than passive reaction to disinterested providers going through the motions.
Chris, agree with your comments. Hopefully, I emphasized that its "traditional," nurse call center based condition-specific DM programs that have failed to demonstrate value. Those that are highly targeted with aligned incentives have more promise.
DeleteWhat is in a "name?" The basic process of identifying a patient with health information and support needs, then addressing them with interventions, and measuring outcomes is a core part of all care delivery, past, present, and future. The limited scope 'payor' based offerings to which this article refers have not succeeded in unambiguously demonstrating their value, but the methods, particularly the use of information technology, are far from 'dead.' These are being adopted, perhaps resurrected?, in Medical Homes, Accountable Care Organizations, adherence programs, and even marketing support programs. Many of the innovation grant applications should be using these same processes, tools, and even measurement strategioes. So, Disease Management is dead. Long live Accountable Care organizations!
DeleteArt, great comments...and I agree that information technology can be very valuable in managing disease (while not in the context of traditional DM). But "Accountable Care Organizations" also run the same risk of failure as DM as accrediting organizations get involved. In addition, the even bigger risk is that the government's shared savings approaches will undermine the opportunity for financial success on the part of ACOs and participating providers. Physicians in large MSP based medical groups have done said to me that even in Year 1, the financial gain from the shared savings isn't worth their time. National experts much smarter than me have very publicly suggested that ACOs are just a transitional strategy since the shared savings will only be meaningful for a few years as the "fat" in the system gets addressed. After that, the savings are likely to be too low to make this a viable business model.
DeleteAs a veteran of the disease management industry, and most recently, spending several years assisting provider organizations to manage their patient populations, I fully appreciate the problems inherent in traditional employer-based and health plan-sponsored disease management programs. However, like Al Lewis, I also disagree with the statement that disease management is dead. Although some models have failed in the past, disease management models continue to evolve and are being transformed and incorporated into new physician-led population health models such as the Patient-Centered Medical Home. Further, as health systems assume more financial risk and move towards Accountable Care Organizations, they will take on responsibility for managing entire populations and will be using population health tools and services that evolved from the original disease management principles and fundamentals.
ReplyDeleteI emphasized several points that strongly indicate that disease management is alive and well on my blog post here:
http://blog.phytel.com/2012/01/death-of-disease-management/