QUALITY: Hope, Hype and Disease Management
A few days ago, we wrote about hype and hopes in health care reform, the constant search for the magic low-cost, high-quality elixir. Soon after, we found ourselves reading several articles and blog posts and attending a panel discussion sponsored by Health Affairs making us wonder whether disease management is the latest example of the hype-hope cycle.
After thinking about it, and reading about it for a few more days (the Health Affairs Jan/Feb 2009 issue focuses on chronic disease), our conclusion is—only sort of. A lot of what's been tried so far hasn't worked—-if you are focusing on disease management within the Medicare fee-for-service context. Luckily that's not the only context. The building interest in gainsharing, payment bundling, integrated delivery systems, medical homes etc. all include some form of managing and coordinating care of chronic disease. The concept still makes sense. Chronic disease is not going away or getting any cheaper. So it needs to be managed. And we are still learning how to do that.
Disease management is just what it sounds like. Managing chronic diseases, like heart failure or diabetes (more accurately, given that so many older Americans have multiple chronic conditions, heart failure AND diabetes), so that patients get coordinated and consistent care rather than letting them lurch from crisis to crisis. Most of the 35 Medicare disease management programs tried since 1999 (within traditional fee for service Medicare) haven't worked all that well, according to David Bott and colleagues writing in Health Affairs. Or they've improved care a little bit but added cost. In general, they didn't improve patient compliance with evidence-based care, they didn't boost satisfaction for either patients or providers, they didn't modify patient behavior and they didn't save money. Nothing like batting 0-for-4. A subset (I believe the current number is 7-out-of-35) did appear to have better outcomes—and those programs have been extended. No one seems quite sure why some of these programs work better than others (or if they are, they haven't said in public pending publication of more data in peer-reviewed journals....) For details on these programs see the current Health Affairs issue, including discussion of the fine points distinguishing "disease management" and "chronic care model."
A few other stray points made at a Health Affairs briefing that were worth keeping in mind:
The programs took several months to get up and running; that meant there was a period of start-up costs but no disease management savings. Programs that are ongoing may shed some more light on savings potentials over a longer term.
Some of the people in the pilot programs were very, very old and very, very sick. A lot died while their diseases were being "managed." Maybe for this population, the focus on "managing" diabetes or high cholesterol was a bit myopic. These patients were crossing that hard-to-perceive line between "chronic" and "terminal" disease, and perhaps what they really needed wasn't statins or insulin adjustments as much as support in advanced care planning, pain and symptom management, and more help with the psychosocial and caregiver aspects of end of life.
For a detailed analysis of the shortfalls of the eight Medicare Health Support programs, see the CMS report to Congress here. If you want to follow developments in disease management in more depth than we do here, check out the the Disease Management Care Blog.