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Article
getting serious about disease management
By
Dave Edwards
Senior Consultant
Despite the uncertainty surrounding the final result of health care
legislation, it’s comforting to know some management challenges
transcend the vagaries of politics and regulatory agencies. One of those
constants is optimization of administrative spend. Traditionally, it is
an area of management focus applicable to all functions including
medical management, of which disease management is a part. It is also an
area of focus that may be elevated to critical importance if Section 102
of House Bill HR 3962 makes its way through committee and into law. This
is the section that mandates, beginning January 1, 2010, at least 85% of
premium dollars for large-group, small-group, and individual policies
must be spent on medical treatment, leaving (at most) 15% for marketing,
sales, administrative expense, other expenses and, for commercial
carriers, profit. In that environment, creating and maintaining an
effective disease management capability presents special challenges, but
this would also present unique opportunities for administrative savings,
cost-of-care benefits for self-insured groups, and marketplace
differentiation.
The importance of disease management as a means to improve members’
quality of life and to help control medical costs should be apparent to
even a casual observer. According to an Archives of Internal Medicine
study in 2004, 57 million Americans suffered from one or more of the
“Big Five” chronic conditions—diabetes, asthma, congestive heart failure
(CHF), coronary artery disease, and chronic obstructive pulmonary
disease. That number is expected to increase to 81 million by 2020.
Seventy-two percent of all physician visits and 88% of all prescriptions
filled are for patients with one or more of these conditions, which is
75% of all medical spending in the United States. Yet, despite the
enormity of the problem, the verdict on the effectiveness of disease
management programs is decidedly mixed and falls into three categories:
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At one end of the spectrum: Individual plan studies showing
meaningful cost of care savings for targeted conditions. |
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At the other end: A recent Congressional Budget Office study
stated there is insufficient data from large, long-term studies to
make any broad statements about disease management programs’
effectiveness in reducing cost of care. |
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And in the middle: A 2005 Society of Actuaries study showed
savings for some condition programs but no savings for others. For
example, an $11–$145 PMPM savings for diabetes programs; $150–$450
PMPM savings for CHF programs; but no savings for asthma programs. |
The unmistakable message from all of this is that health plans are
presented with a growing, complex problem that cannot be solved with
broad brush strokes. Although daunting, it’s a problem we believe can be
effectively addressed, accomplishing the goals of clinical staff
optimization, cost-of-care reductions, and market differentiation.
Effective disease management begins with two guiding principles:
targeted engagement and member behavior modification. Without them,
program benefit expectations will simply not be met. These principles
have eight key tactical considerations which, in aggregate, produce
meaningful, qualitative, and quantitative results.
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Integrity of member contact information—accurate telephone
numbers and e-mail and postal addresses.
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Effective population risk scoring by age, gender, condition,
co-morbidity, and location (by zip code).
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Engagement outreach supported by customized contact
procedures for high-risk/high-potential members. Many programs
fail because all members are treated equally from a procedural
perspective, often resulting in engagement of a preponderance of
lower-potential members.
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Member relationship building using a declining-scale
intervention frequency and contact duration model. Similar to
personal relationship building, contact with members should be
frequent at the beginning with comparatively more time invested
during each contact, then becoming less frequent and less
time-consuming as interim goals are met and trust is developed.
Too often, contact protocols call for semi-monthly or monthly
contact with members which is an ineffective approach to
creating an effective relationship between the plan’s clinician
and the member.
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Optimized post-engagement member contact success ratios
enabled by system-generated reminder e-mails and/or automated
reminder calls to member-directed contact telephone numbers.
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Treatment protocols and associated quantitative and
qualitative improvement goals that correspond to the
declining-scale intervention process noted in #4. Initial goals
should be numerous, incremental toward the ultimate health goal,
and easily attainable. Achievement of goals established later in
the protocol period should require comparatively more effort on
the part of the member.
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Quality-of-life and cost-of-care results reporting compared
to initial member surveys and similar, unmanaged cohort claim
costs.
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Manage caseloads by consistently closing cases at the end of
protocol periods in which optimal health goals are met or for
those members who are in consistent non-compliance with
treatment plans.
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Although not an easy task, thoughtful implementation of
these considerations should help drive success; something that
has eluded the vast majority of the industry.
The Nolan Company wishes you good fortune in 2010. As needs arise, we
would be pleased to speak with you about your medical management
strategies for the new year. |
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