Disease management (health)

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Disease management is defined as "a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant."[1][2][3] It is the process of reducing healthcare costs and/or improving quality of life for individuals by preventing or minimizing the effects of a disease, usually a chronic condition, through integrative care.

Contents

[edit] History

Disease management has evolved from managed care, specialty capitation, and health service demand management, and refers to the processes and people concerned with improving or maintaining health in large populations. It is concerned with common chronic illnesses, and the reduction of future complications associated with those diseases.

Illnesses that disease management would concern itself with would include: coronary heart disease, chronic obstructive pulmonary disease (COPD), kidney failure, hypertension, heart failure, obesity, diabetes mellitus, asthma, cancer, arthritis, clinical depression, sleep apnea, osteoporosis, and other common ailments.

[edit] The disease management industry

In the United States, disease management is a large industry with many vendors. Major disease management organizations based on revenues and other criteria[4][5] include Accordant (a subsidiary of Caremark), Alere (now including ParadigmHealth and Matria)[6], Caremark (excluding its Accordant subsidiary), Evercare, Health Dialog, Healthways, LifeMasters, LifeSynch (formerly Corphealth)[7], Magellan, and McKesson Health Solutions.

Disease management is of particular importance to health plans, agencies, trusts, associations and employers that offer health insurance. A 2002 survey found that 99.5% of enrollees of Health Maintenance Organization/Point Of Service (HMO/POS) plans are in plans that cover at least one disease management program[8]. A Mercer Consulting study indicated that the percentage of employer-sponsored health plans offering disease management programs grew to 58% in 2003, up from 41% in 2002[9].

It was reported that $85 million was spent on disease management in the United States in 1997, and $600 million in 2002[10]. Between 2000 and 2005, the compound annual growth rate of revenues for disease management organizations was 28%[5]. In 2000, the Boston Consulting Group estimated that the U.S. market for outsourced disease management could be $20 billion by 2010[5]; however, in 2008 the Disease Management Purchasing Consortium estimated that disease management organization revenues would be $2.8 billion by 2010[4].

[edit] Process

The underlying premise of disease management is that when the right tools, ...experts, and equipment are applied to a population, then labor costs (specifically: absenteeism, presenteeism, and direct insurance expenses) can be minimized in the near term, or resources can be provided more efficiently. The general idea is to ease the disease path, rather than cure the disease. Improving quality and activities for daily living are first and foremost. Improving cost, in some programs, is a necessary component, as well. However, some disease management systems believe that reductions in longer term problems may not be measureable today, but may warrant continuation of disease management programs until better data is available in 10-20 years. Most disease management vendors offer return on investment (ROI) for their programs, although over the years there have been dozens of ways to measure ROI. Responding to this inconsistency, an industry trade association, DMAA: The Care Continuum Alliance, convened industry leaders to develop consensus guidelines for measuring clinical and financial outcomes in disease management, wellness and other population-based programs. Contributing to the work were public and private health and quality organizations, including the federal Agency for Healthcare Research and Quality, the National Committee for Quality Assurance, URAC, and the Joint Commission. The project produced the first volume of a now four-volume Outcomes Guidelines Report, which details industry-consensus approaches to measuring outcomes.

Tools include web-based assessment tools, clinical guidelines, health risk assessments, outbound and inbound call-center-based triage, best practices, formularies, and numerous other devices, systems and protocols.

Experts include actuaries, physicians, medical economists, nurses, nutritionists, physical therapists, statisticians, epidemiologists, and human resources professionals. Equipment can include mailing systems, web-based applications (with or without interactive modes), monitoring devices, or telephonic systems.

[edit] Studies of effectiveness of disease management

[edit] Possible biases in effectiveness studies

When disease management programs are voluntary, studies of their effectiveness may be affected by a self-selection bias; that is, a program may "attract enrollees who were [already] highly motivated to succeed"[11]. A 2009 study found that people who enrolled in one disease management program "differed significantly from those who did not on demographic, cost, utilization and quality parameters prior to enrollment"[12]. To minimize any bias in estimates of the effectiveness of disease management due to "baseline differences in study group characteristics," randomized controlled trials are better than observational studies[13].

[edit] Medicare Health Support project, 2005-present

Section 721 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 authorized the Centers for Medicare and Medicaid Services (CMS) to conduct what became the "Medicare Health Support" project to examine disease management[14]. Phase I of the project involved disease management companies (such as Aetna Health Management, CIGNA Health Support, Health Dialog Services Corp., Healthways, and McKesson Health Solutions) chosen by a competitive process in eight states and the District of Columbia[14]. The project focused on people with diabetes or heart failure who had relatively high Medicare payments; in each location, approximately 20,000 such people were assigned to an intervention group and 10,000 to a control group[15]. CMS set goals in the areas of clinical quality and beneficiary satisfaction, and negotiated with the disease management programs for a target of 5% savings in Medicare costs[16]. The programs started between August 2005 and January 2006[14]. What is now DMAA: The Care Continuum Alliance praised the project as "the first-ever national pilot integrating sophisticated care management techniques into the Medicare fee-for-service program"[17].

An initial evaluation of Phase I of the project by RTI International appeared in June 2007 which had "three key participation and financial findings"[15]:

  • Medicare expenditures for the intervention group were higher than those of the comparison group by the time the pilots started.
  • Within the intervention group, participants had lower Medicare payments (i.e., tended to be healthier) than non-participants.
  • The "fees paid to date far exceed any savings produced."

DMAA focused on another finding of the initial evaluation, the "high levels of satisfaction with chronic disease management services among beneficiaries and physicians"[18]. One commentary noted that the project "can only be observational" since "equivalence was not achieved at baseline"[19]. Another commentary claimed that the project was "in big trouble"[20]. A paper on the six-month evaluation, published in fall 2008, concluded that "Results to date indicate limited success in achieving Medicare cost savings or reducing acute care utilization"[21].

In December 2007, CMS changed the financial threshold from 5% savings to budget neutrality, a change that DMAA "hailed"[16][22]. In January 2008, however, CMS decided to end Phase I because it claimed that the statutory authority had run out[23]. Four U.S. senators wrote a letter to CMS to reverse its decision[24]. DMAA decried the termination of Phase I and called upon CMS to start Phase II as soon as possible[25][26]. Among other criticisms of the project, the disease management companies claimed that Medicare "signed up patients who were much sicker than they had expected," failed to transmit information on patients' prescriptions and laboratory results to them in a timely fashion, and disallowed the companies from selecting patients most likely to benefit from disease management[27].

By April 2008, CMS had spent $360 million on the project, and the final results on the approximately 160,000 participants were expected in 2009[27]. The individual programs ended between December 2006 and August 2008[14].

[edit] Other studies

Studies that have reviewed other studies on the effectiveness of disease management include the following:

  • A 2004 Congressional Budget Office analysis concluded that published studies "do not provide a firm basis for concluding that disease management programs generally reduce total costs"[2]. The report caused the disease management industry to "scrambl[e] to build a better business case for their services"[28].
  • A 2005 review of 44 studies on disease management found a positive return on investment (ROI) for congestive heart failure and multiple disease conditions, but inconclusive, mixed, or negative ROI for diabetes, asthma, and depression management programs.[29] The lead author, of Cornell University and Thomson Medstat, was quoted as saying that the paucity of research conducted on the ROI of disease management was "a concern because so many companies and government agencies have adopted disease management to manage the cost of care for people with chronic conditions."[10]
  • A 2007 RAND summary of 26 reviews and meta-analyses of small-scale disease management programs, and 3 evaluations of population-based disease management programs, concluded that "Payers and policy makers should remain skeptical about vendor claims [concerning disease management] and should demand supporting evidence based on transparent and scientifically sound methods."[30] In specific:
    • Disease management improved "clinical processes of care" (e.g., adherence to evidence-based guidelines) for congestive heart failure, coronary artery disease, diabetes, and depression.
    • There was inconclusive evidence, insufficient evidence, or evidence for no effect of disease management on health-related behaviors.
    • Disease management led to better disease control for congestive heart failure, coronary artery disease, diabetes, and depression.
    • There was inconclusive evidence, insufficient evidence, or evidence for no effect of disease management on clinical outcomes (e.g., "mortality and functional status").
    • Disease management reduced hospital admission rates for congestive heart failure, but increased health care utilization for depression, with inconclusive or insufficient evidence for the other diseases studied.
    • In the area of financial outcomes, there was inconclusive evidence, insufficient evidence, evidence for no effect, or evidence for increased costs.
    • Disease management increased patient satisfaction and health-related quality of life in congestive heart failure and depression, but the evidence was insufficient for the other diseases studied.
A subsequent letter to the editor claimed that disease management might nevertheless "satisfy buyers today, even if academics remain unconvinced"[31].
  • A 2008 systematic review and meta-analysis concluded that disease management for COPD "modestly improved exercise capacity, health-related quality of life, and hospital admissions, but not all-cause mortality"[32].

Recent studies not reviewed in the aforementioned papers include the following:

  • A U.K. study published in 2007 found certain improvements in the care of patients with coronary artery disease and heart failure (e.g., better management of blood pressure and cholesterol) if they received nurse-led disease management instead of usual care[33].
  • In a 2007 Canadian study, people were randomized to receive or not receive disease management for heart failure for a period of six months. Emergency room visits, hospital readmissions, and all-cause deaths were no different in the two groups after 2.8 years of follow-up[34].
  • A 2008 U.S. study found that nurse-led disease management for patients with heart failure was "reasonably cost-effective" per quality-adjusted life year compared with a "usual care group"[35].
  • A 2008 study from the Netherlands compared no disease management with "basic" nurse-led disease management with "intensive" nurse-led disease management for patients discharged from the hospital with heart failure; it detected no significant differences in hospitalization and death for the three groups of patients[36].
  • A retrospective cohort study from 2008 found that disease management did not increase the use of drugs recommended for patients after a heart attack[37].
  • Of 15 care coordination (disease management) programs followed for two years in a 2008 study, "few programs improved patient behaviors, health, or quality of care" and "no program reduced gross or net expenditures"[38].
  • After 18 months, a 2008 Florida study found "virtually no overall impacts on hospital or emergency room (ER) use, Medicare expenditures, quality of care, or prescription drug use" for a disease management program[39].
  • With minor exceptions, a paper published in 2008 did not find significant differences in outcomes among people with asthma randomly assigned to telephonic disease management, augmented disease management (including in-home respiratory therapist visits), or traditional care[40].
  • A 2009 review by the Centers for Medicare and Medicaid Services of 35 disease management programs that were part of demonstration projects between 1999 and 2008 found that relatively few improved quality in a budget-neutral manner[41].
  • In a 2009 randomized trial, high- and moderate-intensity disease management did not improve smoking cessation rates after 24 months compared with drug therapy alone[42].
  • A 2009 study using data from a clinical trial estimated that health care costs including disease management for heart failure would be $91,206 over a lifetime, versus $85,827 for the health care costs without disease management[43]. Furthermore, the authors estimated that the cost-effectiveness of disease management in this situation was $43,650 per quality-adjusted life year saved[43].
  • A 2009 review of 27 studies "could not draw definitive conclusions about the effectiveness or cost-effectiveness of... asthma disease-management programs" for adults[44].

[edit] See also

[edit] References

  1. ^ DMAA: The Care Continuum Alliance. DMAA definition of disease management. Retrieved 2008-12-04.
  2. ^ a b Congressional Budget Office. An analysis of the literature on disease management programs. 2004-10-13. Retrieved 2008-10-13.
  3. ^ Coughlin JF, et al. Old age, new technology, and future innovations in disease management and home health care. Home Health Care Management & Practice 2006 Apr;18(3):196-207. Retrieved 2009-01-09.
  4. ^ a b Leading disease management organizations. Santa Cruz, CA: Health Industries Research Companies, 2008 Summer. Retrieved 2008-12-16.
  5. ^ a b c Matheson D, et al. Realizing the promise of disease management. Payer trends and opportunities in the United States. Boston: Boston Consulting Group, 2006 February. Retrieved 2008-12-16.
  6. ^ Alere. History. A member of the Inverness Medical Innovations (AMEX: IMA) family of companies, Alere® was formed in 2008 when Inverness purchased and then merged three healthcare companies – Alere Medical, ParadigmHealth and Matria® Healthcare. Retrieved 2009-07-15.
  7. ^ Corphealth Changes Brand Name to LifeSynch. Humana's Your Practice, 2008 Fourth Quarter. Retrieved 2009-07-15.
  8. ^ America’s Health Insurance Plans. 2002 AHIP survey of health insurance plans: chart book of findings. Washington, DC: AHIP, 2004 April. Retrieved 2008-12-04.
  9. ^ Landro L. Does disease management pay off? Wall Street Journal, October 20, 2004.
  10. ^ a b Lau G. Study questions effectiveness of disease management. Investor's Business Daily, 2005-10-03.
  11. ^ Kominski GF, et al. The effect of disease management on utilization of services by race/ethnicity: evidence from the Florida Medicaid program. American Journal of Managed Care 2008 Mar;14(3):168-72. Retrieved 2009-04-03.
  12. ^ Buntin MB, et al. Who gets disease management? Journal of General Internal Medicine 2009 Mar 24. Retrieved 2009-04-03.
  13. ^ Linden A, et al. Strengthening the case for disease management effectiveness: un-hiding the hidden bias. Journal of Evaluation in Clinical Practice 2006 Apr;12(2):140-7. Retrieved 2009-04-03.
  14. ^ a b c d Centers for Medicare & Medicaid Services. Medicare Health Support. Regional programs. 2008-09-26. Retrieved 2008-12-07.
  15. ^ a b McCall N, et al. Evaluation of Phase I of Medicare Health Support (Formerly Voluntary Chronic Care Improvement) pilot program under traditional fee-for-service Medicare. Report to Congress. 2007 June. Retrieved 2008-12-07.
  16. ^ a b Centers for Medicare & Medicaid Services. Fact sheet. Completion of Phase I of Medicare Health Support Program. 2008-01-28. Retrieved 2008-12-07.
  17. ^ Disease Management Association of America (DMAA). Medicare Health Support off to 'outstanding' start. Disease management association hails program's progress. 2006-02-03. Retrieved 2008-12-07.
  18. ^ Moorhead, Tracey. DMAA statement on Medicare Health Support report to Congress. 2007-07-06. Retrieved 2008-12-07.
  19. ^ Wilson, Thomas. National expert critiques MHS initial analysis. A critique of baseline issues in the initial Medicare Health Support Report. Disease Management Viewpoints blog, 2007-07-18. Retrieved 2008-12-07.
  20. ^ Wilson, Thomas, and Vince Kuraitis. Disease management and the Medicare Health Support (MHS) Project: "Houston, we have a problem." e-CareManagement blog, 2007-09-06. Retrieved 2008-12-07.
  21. ^ Cromwell J, et al. Evaluation of Medicare Health Support chronic disease pilot program. Health Care Financing Review 2008 Fall;30(1):47-60. Retrieved 2008-12-07.
  22. ^ DMAA: The Care Continuum Alliance. DMAA hails decision on financial threshold for Medicare Health Support. 2008-01-08. Retrieved 2008-12-07.
  23. ^ Centers for Medicare & Medicaid Services. Completion of Phase I of Medicare Health Support program. FAQs. 2008-01-29. Retrieved 2008-12-07.
  24. ^ DoBias M. Senators press CMS on disease-management pilot program. Modern Healthcare, 2008-03-17.
  25. ^ Moorhead, Tracey. Statement on CMS announcement regarding Phase I of Medicare Health Support. 2008-01-30. Retrieved 2008-12-07.
  26. ^ Moorhead T. Don't fly off handle after a pilot test; feds, private sector must not abandon the promise of disease management. Modern Healthcare, 2008-03-24.
  27. ^ a b Abelson R. Medicare finds how hard it is to save money. New York Times, 2008-04-07. Retrieved 2008-12-07.
  28. ^ Benko LB. Payers and purchasers: numbers that count. Disease-management industry is taking steps to deliver more reliability, consistency in data on program outcomes. Modern Healthcare, 2007-01-15.
  29. ^ Goetzel RZ, et al. Return on investment in disease management: a review. Health Care Financing Review 2005 Summer;26(4):1-19.
  30. ^ Mattke S, et al. Evidence for the effect of disease management: is $1 billion a year a good investment? American Journal of Managed Care 2007 Dec;13(12):670-6.
  31. ^ Norman GK. All things considered, the answer is a resounding yes. American Journal of Managed Care 2008 Jan;14:e2-e4. Retrieved 2008-12-06.
  32. ^ Peytremann-Bridevaux I, et al. Effectiveness of chronic obstructive pulmonary disease-management programs: systematic review and meta-analysis. American Journal of Medicine 2008 May;121(5):433-443. Retrieved 2009-04-03.
  33. ^ Khunti K, et al. Disease management programme for secondary prevention of coronary heart disease and heart failure in primary care: a cluster randomised controlled trial. Heart 2007;93:1398-405. Retrieved 2008-12-06.
  34. ^ Nguyen V, et al. Lack of long-term benefits of a 6-month heart failure disease management program. Journal of Cardiac Failure 2007;13:287-93.
  35. ^ Hebert PL, et al. Cost-effectiveness of nurse-led disease management for heart failure in an ethnically diverse urban community. Annals of Internal Medicine 2008;149:540-8. Retrieved 2008-12-06.
  36. ^ Jaarsma T, et al. Effect of moderate or intensive disease management program on outcome in patients with heart failure: Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH). Archives of Internal Medicine 2008;168:316-24. Retrieved 2008-12-06.
  37. ^ Chan V, Cooke CE. Pharmacotherapy after myocardial infarction: disease management versus usual care. American Journal of Managed Care 2008;14:352-8. Retrieved 2008-12-09.
  38. ^ Brown R, et al. 15-site randomized trial of coordinated care in Medicare FFS. Health Care Financing Review 2008;30:5-25. Retrieved 2008-12-09.
  39. ^ Esposito D, et al. Impacts of a disease management program for dually eligible beneficiaries. Health Care Financing Review 2008;30:27-45. Retrieved 2008-12-09.
  40. ^ Galbreath AD, et al. Assessing the value of disease management: impact of 2 disease management strategies in an underserved asthma population. Annals of Allergy, Asthma & Immunology 2008 Dec;101(6):599-607. Retrieved 2009-04-03.
  41. ^ Bott DM, Kapp MC, Johnson LB, Magno LM. Disease management for chronically ill beneficiaries in traditional Medicare. Health Affairs 2009 Jan-Feb;28(1):86-98. PMID 19124858. Retrieved 2009-07-15.
  42. ^ Ellerbeck EF, Mahnken JD, Cupertino AP, Cox LS, Greiner KA, Mussulman LM, Nazir N, Shireman TI, Resnicow K, Ahluwalia JS. Effect of varying levels of disease management on smoking cessation: a randomized trial. Ann Intern Med 2009 Apr 7;150(7):437-46. PMID 19349629. Retrieved 2009-07-15.
  43. ^ a b Miller G, Randolph S, Forkner E, Smith B, Galbreath AD. Long-term cost-effectiveness of disease management in systolic heart failure. Med Decis Making 2009 May-Jun;29(3):325-33. PMID 19147835. Retrieved 2009-07-15.
  44. ^ Maciejewski ML, Chen SY, Au DH. Adult asthma disease management: an analysis of studies, approaches, outcomes, and methods. Respir Care 2009 Jul;54(7):878-86. PMID 19558739. Retrieved 2009-07-15.

[edit] Further reading

  • Todd, Warren E., and David B. Nash. Disease management: a systems approach to improving patient outcomes. Chicago: American Hospital Pub., 1997. ISBN 1556481683
  • Couch, James B. The health care professional's guide to disease management: patient-centered care for the 21st century. Gaithersburg, MD: Aspen Publishers, 1998. ISBN 0834211661
  • Patterson, Richard. Changing patient behavior: improving outcomes in health and disease management. San Francisco: Jossey-Bass, 2001. ISBN 0787952796
  • Disease management for nurse practitioners. Springhouse, PA: Springhouse, 2002. ISBN 1582550697
  • Howe, Rufus S. The disease manager's handbook. Sudbury, MA: Jones and Bartlett, 2005. ISBN 0763747831
  • Huber, Diane. Disease management: a guide for case managers. St. Louis: Elsevier Saunders, 2005. ISBN 0721639119
  • Nuovo, Jim, editor. Chronic disease management. New York, NY: Springer, 2007. ISBN 9780387329277

[edit] External links

Retrieved from "http://en.wikipedia.org/wiki/Disease_management_(health)"
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