New Health Dialogue - logo
 

COST: For Disease Management, the Doctor Must Be In

Joanne Kenen - 
April 8, 2008 - 9:54am

When we saw Monday's New York Times report on how Medicare's experiment in disease management was not cutting costs, we asked Robert Berenson MD, Senior Fellow at The Urban Institute, to comment. Here's what he had to say:

Disease management for patients with chronic conditions is supposed to pick off the "low hanging fruit" of cost containment, both in Medicare as well as among self-funded private employers and commercial health insurers. In each of these settings, about 5 percent of subscribers/beneficiaries are responsible for more than 40 percent of the health costs, and 20 percent of the patients run up 80 percent of the costs. Many of these patients have one or more underlying chronic conditions, such as congestive heart failure (CHF) or diabetes.

Surely, the thinking goes, we can easily find savings by applying better management techniques. We can use telephone or web-based communication tools for better surveillance. We can teach patients self-management skills. And we can do all this, the thinking went, without having to interfere with the physician-patient relationship. Indeed, presidential campaigns typically assume substantial savings from disease management-type initiatives targeted to the high spending associated with patients with chronic conditions.

Based largely on anecdotal reports of great success by third-party disease management vendors and effective lobbying, Congress in the Medicare Modernization Act of 2003 commissioned a pilot test of disease management for patients with CHF and diabetes. Unfortunately, as the New York Times April 7 article by Reed Abelson, "Medicare Finds How Hard It Is to Save Money" documents, this three-year pilot failed to save money.

Every once in a while a seasoned (or crotchety) policy analyst gets to say, "I told you so." And it's my turn to say it now. Shortly after this Chronic Care Improvement (CCI) pilot was authorized, I testified before the Ways and Means Subcommittee on Health, warning the lawmakers that business techniques could only go so far in managing disease without the involvement of doctors:

"Although the CCI program may be a good start, in my opinion it is insufficient for truly addressing chronic care needs in Medicare because it lacks a focused physician component. The Administration emphasizes that the new program creates a 'business platform' that will permit innovation, but the CCI program ignores the reality that beneficiaries look to their personal physicians for responsibility for their health care—and not business platforms—whether health plans, disease management companies, or other third-party vendors."

Some elements of the disease management industry say the pilot failed to save money because CMS implemented it poorly. It's more likely that the failure belongs more with the "physician bypass" logic of the approach. Implementation problems notwithstanding, if this approach cannot achieve robust savings on congestive heart failure—the "poster child" of a condition responsible for avoidable, expensive hospitalizations and supposedly amenable to disease management interventions—one has to question whether it can possibly work to reduce spending for patients with assorted other chronic conditions. In fact, some disease management companies now are exploring how to change their approach to become an extension of the physician's office, rather than primarily an external party trying to engage the patient.

For more than 30 years Medicare has tried and failed in many other demonstrations to reduce costs associated with frail elderly and non-frail seniors with multiple chronic conditions—but without the direct involvement of patients' physicians. It is time to try to include, rather than bypass, physicians in chronic care management and coordination. That is where the so-called "patient-centered medical home" comes in. But that is another story.

(New America's Health Policy Program director Len Nichols and Berenson are co-directing a study on Medicare reform, specifically about how to make Medicare a value-based purchaser. They will release their first round of papers this July.)

Bookmark/Search this post with:
  • Delicious
  • Digg
  • StumbleUpon
  • Propeller
  • Reddit
  • Magnoliacom
  • Newsvine
  • Furl
  • Facebook
  • Google
  • Yahoo
  • Technorati
  • Icerocket
Tags:

Comments

Disease Management

Submitted by Kathleen Moran (not verified) on January 25, 2009 - 11:38am.

I'm a nurse who worked for a disease management program. I agree physicans need to be involved with disease management. I would suggest that hospitals need to run their own disease management programs so that the PCP's would be involved with the members care. The place I worked for based care on a business model rather than a health care model. The quality of what was being delivered left the member as well as the practioner wondering what the point of the program was. If the focus is constantly on saving money or someone else getting a piece of the pie than my view is it won't work. Collectively, we need to learn to focus on delivering quality care to the largest number of people possible. If the quality and standards of care are lacking of course you won't see any savings. Let's keep the focus on improving, maintaining or managing a patients care to the best of the patients abilities at the time they enter the program.

docs and better health care

Submitted by Diane E. Meier (not verified) on April 14, 2009 - 6:00pm.

It is so refreshing to read this post! As a practicing physician, geriatrician, and palliative medicine physician working in a large acaedmic medical center in a big city, I want to support Bob Berenson's opinion in the strongest possible terms. It does not matter if you have an advance directive; or if your hospital is measuring ventilator acquired pneumonia rates as a quality indicator; or if your 7 specialty consultants are all smart and board certified- if the oncologist says "I think we should check another PET scan next month" or "Let's give xyz chemotherapy a try now that 3rd round chemo has failed" no sick patient will argue. We assume our doctors are making the best possible judgements on our behalf and that they would not recommend something unlikely to be of help- what patients do not realize is the countervailing pressures on these doctors to get the encounter done quickly and move on to the next person. It is faster to order a test or a drug infusion (and far more remunerative) than to listen and talk to patients and their families. Simple as that.

When we are sick and exhausted and stressed and overwhelmed by illness, we do what our doctors recommend to us. When our doctors are stressed and rushed and have to see 30 patients in an afternoon, and only get paid for administering chemptherapy or doing a procedure, the results are predictable. As is oft repeated in this field, the system is perfectly designed to get the results that it gets. Doctors do what is expected of them- high volume throughput (RVUs measured by number of patient encounters per unit time and salaries are based on achieving a minimum number of RVUs), more procedures, and a huge premium on time. Nothing is in shorter supply or more precious to the physician than time. Long discussions with patients and families about what is happening, what it means, what the realistic and feasible options are, are not only not reimbursed at a level anywhere near commensurate with the skill and time and effort required, but under current CMS CPT2008 billing guidelines are, under many circumstances, not reimbursed at all (for example, if the patient is comatose and the family is the decision maker, a 90 minute meeting with the family is not currently billable because it did not occur face to face with the patient).
This would be funny if it weren't true.
Furthermore, we need to talk more about medical education reform if we are ever to accomplish health system reform. It might be reassuring to know that doctors typically practice as they were trained- hence the consistency from region to region in the context of the wide national variability in practice patterns across the country- so if we train differently, docs will practice differently. Right now most docs are trained primarily in the acute care teaching hospital and all they see is highly procedural subspecialty medicine- and what they see is what they become. To fix this, medical schools and residencies must be required to provide rigourous and substantial exposure to primary care fields, geriatric medicine, palliative medicine and to assure that their trainees can demonstrate a high level of competency in these areas. We must pay physicians in these fields a wage adequate to raise a family and pay back their huge medical school loans. We must create loan forgiveness programs to incent entry into primary and comprehensive care fields like general medicine, pediatrics, geriatrics, palliative medicine. Right now, people who enter these fields are either independently wealthy, have parents or spouses who can support their hobby, or are the Mother Teresa's among us. Not a sturdy basis for a rational policy.
Until we realize that it doesn't matter what you do if you don't change the training and the incentives driving usual physician practice patterns, no amount of talk or action about healthcare reform will work.