Hospices swim upstream with disease management

Relationships with DM firms may bring success

Disease management is one of the hottest buzzwords in managed care. Some observers even see it as the future of hospice. While definitions are hazy and even contradictory, many of the conditions targeted by disease management companies are the same diseases hospices aim to serve. Disease management's approach of managing all aspects of care for a given condition also resembles what hospices have been doing for years under the Medicare hospice benefit. If hospices are to swim "upstream" and become involved in the care of people with life-limiting illnesses long before the brink of death, disease management may be the stroke, either in partnership with disease management specialty firms or on their own. But first, it would help to gain clarity on the term.

Disease management or money management?

Articles in the health care trade press, conferences, sourcebooks and even a newsletter called Disease Management News tout DM as a coming trend and an important focus for managed care activity. The earliest DM firms tended to be pharmaceutical companies, which were also looking to corner a bigger slice of the health care market than they could get for their drugs alone. DM firms have targeted arthritis, asthma, cancer, chronic obstructive pulmonary disease (COPD), diabetes, epilepsy, heart disease, hemophilia, HIV, and other conditions that are perceived by managed care as high-cost outliers.

"The term means different things to me than it does to mainstream health care," says J.R. Williams, MD, chief patient care officer for the Miami-based Vitas hospice chain. "To some extent I lump disease management and case management together," with their origins in the niches created by forward-thinking medical groups that first learned how to manage the care of patients with serious (and expensive) medical conditions. Much of the focus was on patient/ family education, utilizing other health disciplines, and managing the patient over the phone and between medical office visits, he relates.

"The way a hospice interdisciplinary team managed a particular patient and family was the ultimate in case management," in contrast to managed care case managers who never actually saw the patient and functioned more as health services brokers, Williams says. "I never believed that was true case management. Now disease management has started the [redefinition] process all over again." Williams defines DM has an effective educational intervention directed at a patient's disease, with the goal of more effectively managing that disease at home. Managed care companies may pay a fee to the DM firm, in the hope that overall costs will be reduced, or they may pass on the financial risk under a capitated payment for the defined population.

"In today's managed care climate, physicians are asked to see more patients in less time, and aren't in a position to do that kind of education. Hence the success of the disease management company that steps in and does a good job of managing the disease and comorbid conditions, looking at the patient in the home environment and educating the family and the patient. This is best done by an organization whose primary intent is to manage the patient's disease or diseases."

The advantage for a hospice to hook up with a DM firm, as Vitas has done with CardioContinuum of Rockville, MD, is the DM company doesn't have to limit itself to the final six months of life. "The hospice can work with the disease management company to identify patients who are hospice-appropriate sooner," Williams says. Vitas is also discussing such relationships with other companies in the field and plans to test such joint ventures.

Who heads the group?

Barry Smith, CEO and president of VistaCare, an emerging multi-state hospice company (see also the News Briefs, p. 91, and pp. 72-73 of last month's HMA), used to head a pioneering DM firm, Value Health, which spawned Value Behavioral Health, today the country's largest provider of managed behavioral health care. "From our perspective, disease management meant organizing a health care system around a disease category, defining a population by disease and treating that population based on defined protocols," Smith tells HMA. "That same concept, selling a complete delivery system for a specific condition to employers and insurers, can also be applied to other diseases. But your rule set must be crisply defined - both in terms of the patient population, and in having an intelligent tool kit to manage those patients to deliver higher-quality care and save money," Smith says.

"In the world of hospice, we have a specialty in the disease condition of terminal illness. We are able to come in with that specialty at the end of life and treat the patients, regardless of their primary disease." The problem, he says, lies in hospice's six-months-or-less requirement and its sharp distinction between curative treatment and palliative hospice care.

"Instead of looking at the patient as defined by the payment system, we as an industry need to apply the same models of integrated health care and move upstream, working with local and national physician groups and disease management firms. Of course, we can't sell those services as `hospice,' and it's not the Medicare benefit anymore." But hospice agencies could attach their services to DM companies targeting, for example, certain kinds of cancer, COPD, and congestive heart failure. "Hospice thus becomes a component of disease management, and the hospice team's capacities are expanded."

Smith says that hospice's skills can be sold in this way under capitated risk arrangements. "We don't sell hospice care, we sell management of an entire disease. In my opinion, hospice is the most developed and most appropriate model to really deliver this kind of care to a defined set of patients. Although hospice needs to be part of the group mobilizing the services, the key question is who heads up the group?" There is a danger that hospice could be an afterthought, unless it is a genuine partner with the physician group. VistaCare is about to launch such a partnership with the largest oncology medical group in Indiana, Smith says. "We're not proposing to acquire physician groups. I don't think that's smart. But we're not an afterthought. We're true partners, and we need to be in the forefront of taking risk."

"We all know in our day-to-day hospice lives that certain diseases have general trajectories that can be predicted, from resource, staffing, and symptom management perspectives," observes J. Donald Schumacher, PsyD, president and CEO of the Center for Hospice and Palliative Care, in Cheektowaga, NY. "Here, we're trying to devise a couple of different models of disease management for a couple of specific diseases." In this case, however, the disease management would be done internally, and within the structure and payment of the Medicare hospice benefit. The hospice industry "is so convinced that nobody from outside hospice has something to teach us. In fact, there's a lot we can learn about how to predict disease trajectory" from the DM industry, Schumacher says.

"I would advise hospices to look into their marketplace. See if disease management companies are operating. Call them up. Go sit down and talk with them," Williams urges. "In the future, affiliations and arrangements hospices have with other health care providers will mean a lot, especially as managed care organizations become more like insurance companies and push the risk and responsibility for managing patients down to other groups."