Use common sense, not emotion, to plan DM

How to make the buy-or-build decision

Blue Cross/Blue Shield of Texas in Richardson has debated for the past year whether its members would be better served if they outsourced their disease management efforts or developed their own programs.

Blue Cross and Blue Shield of Georgia in Atlanta recently contracted with SDMS, a health care and disease management consulting company in Wilmington, DE, to pull all of its member data into one integrated data set so the payer can look closely at its population and spend its disease management dollars wisely.

"Disease management is a hot issue right now for health plans. It’s an emotional decision whether to build your own program for common illnesses such as diabetes and asthma or buy a program from a vendor," says Wayne K. Hoffman, MD, vice president of medical management for Blue Cross and Blue Shield of Georgia.

"We’re trying to avoid making an emotional decision or choosing a popular program, such as asthma, until we first look closely at our population to see which are our real problem areas. Too many times, plans implement disease management initiatives based on their costs. But those high costs for asthma or diabetes may be based on a handful of complex patients. You don’t need a disease management program for just a few patients," he says.

After identifying where to focus its disease management efforts, Hoffman says, the decision whether to buy or build a program will depend on the diseases targeted and the resources necessary. "We may decide to develop our own programs with the help of a consulting firm. We may decide to use the programs of a vendor with our own oversight. Once all the data is collected, it will be presented to our regional medical directors, and then the decision-making process will begin." (For tips on how to select a disease management vendor, see story, p. 108.)

The combo platter

Other health plans like the idea of combining materials from other sources with in-house expertise. "We originally thought about outsourcing our disease management programs, but most of the available programs were pharmaceutical-based, and we wanted something that offered more than education and that focused on more than one aspect of the disease," says B.K. Kizziar, RNC, CCM, CLCP, case management consultant for Blue Cross/Blue Shield of Texas.

The health plan then weighed the time and expense involved with developing its own programs from the ground up, Kizziar says. "We decided we just didn’t have time to reinvent the wheel. So we set our own objectives and then went shopping for a vendor who would be able to meet those objectives and customize to meet our needs."

Blue Cross/Blue Shield of Texas plans to focus its initial disease management efforts on asthma, diabetes, and cardiovascular disease, notes Kizziar, adding that the payer already has perinatal and HIV programs in place. The health plan is considering using a home health agency to deliver the hands-on care, conduct surveys, and collect outcomes data.

"We’ll probably incorporate the home health services with parts of educational services offered by the pharmaceutical companies — just put together pieces of existing programs to make our own customized program," Kizziar says.

Integrating non-proprietary materials available from outside sources with internal disease management initiatives makes good financial sense, says Peggy Pardoe, RN, BSN, CCM, CPHQ, clinical services coordinator for University Care with the University of Maryland Medicine in Baltimore.

"When I was working for a health maintenance organization in Maryland, we used education materials available from pharmaceutical companies and national health associations, and we used national guidelines available from the government to complement our program. You don’t have to insist that everything be homegrown. By combining your in-house expertise and available materials and resources, you can have a quality program up and running in a short period of time."

Avoid the free-and-easy fix

However, she cautions that health plans should not use educational materials or practice guidelines simply because they are free and easily available. "Challenge vendors to demonstrate how their treatment guidelines and educational materials can make a fit with your organization’s disease management strategies. Review all the available materials carefully to make sure they fit in with the principles of your program," says Pardoe, adding that many tertiary facilities often make good partners for disease management initiatives.

"You also have to look carefully at literacy levels for all patient education materials. There were a lot of attractive materials I liked, but they were written at an eighth-grade level. I think it’s best to stay with materials written at no higher than a fifth-grade level."

For most payers, the decision to buy or build a disease management program comes down to resource consumption, Pardoe says. "For some chronic illnesses, you can get a lot of mileage from fairly simple things easily done in-house," she says. "For example, asthma is often easier to manage because most asthmatics see only a handful of specialists who need to reach consensus on approaches to treatment. Diabetics and cancer patients, on the other hand, see multiple specialists, and it becomes more difficult to coordinate treatment."

"You have to make tough decisions and ask tough questions about whether you have the people internally to do it right," she says. (For suggestions on how to evaluate the programs offered by disease management companies, see p. 108.)

Questions Pardoe says payers must answer honestly include:

• Is the program we are designing case- management based?

• How many case managers do you need to responsibly manage the population?

• Are we focusing on prevention and education only?

• Can we provide adequate follow up and a continuum of proactive intervention for members in disease management programs?

"As more managed care plans become certi-fied by the National Committee on Quality Assurance [NCQA], they’re going to find that adequate follow up is essential to disease management," Pardoe predicts. "NCQA wants to see the outcomes that show you made an impact. There’s an old saying nurses hear in school that says it doesn’t matter what you taught the patient, only what the patient learned. If they didn’t learn, then you didn’t complete the task."

Finding the money

Providing a quality disease management program with adequate follow up is a desirable goal, but paying for it is another issue, Kizziar notes. "We simply do not have the budget to go out and buy a nice disease management program," she says. "We’re preparing to go to our large self-insured groups and suggesting we modify their regular benefits packages slightly so that we can offer them these new benefits. We think we may suggest that existing home health or extended care benefits be modified to encompass teaching and wellness visits," she explains.

The difficult part of selling this concept to the payer’s self-insured groups is that Blue Cross/ Blue Shield of Texas anticipates an initial rise in utilization, Kizziar says.

"We will be paying for services we haven’t covered in the past. What we have to argue now is that we anticipate the trend will reverse itself and claims will go down due to decreases in hospitalizations and emergency room visits," she says. "Our groups are voicing a desire for these programs. We’re asking them to give us their commitment to see us through the first 12 months of increased use."