Disease management can improve patients’ health and your bottom line

Take steps now to reduced complications down the road

If you have a lot of patients with chronic conditions and are facing the possibility of assuming financial risk for their care, a disease management program may work wonders for your bottom line.

A disease management program improves clinical quality of care by ensuring that the best practices for that condition or disease are actually used on a day-to-day basis. It reduces costs by keeping the disease under control, thereby reducing hospital days and emergency room visits. And, it can give your practice a positive image in the community.

"Patients and prospective patients view it as positive to know that the group practice has specific programs in specific areas," says Richard Lopez, MD, associate medical director for Harvard Vanguard Medical Associates, a fully capitated 550-physician multispecialty group practice in Boston.

Disease management programs are gaining in popularity as provi ders try to get a handle on health care costs. For instance, diabetics make up less than 3.5% of the population, but they account for almost 16% of all acute care hospital days and more than 11% of emergency room visits, according to data from the Sachs Group, a research organization in Evanston, IL. In 1997, diabetes accounted for $138 billion in health care costs and lost productivity, according to Sachs research.

Patient participation in disease management programs increased 300% last year, according to the statistics from the newly formed Disease Management Association of America in Wellesley Hills, MA.

A typical disease management program includes an educational component, regular clinic visits, and follow-up phone calls by clinicians who remind patients to follow their care plan, check their symptoms, and alert the physician if anything seems amiss.

Disease management case managers are the "eyes and ears of the practicing physician," says Al Lewis, association president and executive director of the Disease Management Purchasing Consortium in Newton, MA.

"Disease management is designed to help patients improve their lifestyles and compliance between visits to the physician. It’s one of the most important developments in health care delivery to emerge in the last decade," Lewis says.

Patients with chronic diseases that are under control are less likely to go to the emergency room or into the hospital.

Health plans have been reaping the benefits of disease management for years. As physician practices become larger and get more involved in capitation contracts, they’re seeing the benefits of disease management programs for their chronically ill patients.

For instance, Harvard Vanguard Medical Associ ates has developed disease management programs for asthma, HIV, congestive heart failure, and secondary prevention of coronary disease.

The practice is piloting a depression management program and is about to launch programs for diabetes and chronic obstructive pulmonary disease, Lopez says.

Healthier patients

"The basic value from disease management is healthier people who cost the health system less money," says Robert Stone, president of Diabetes Treatment Centers of America in Nashville, TN. For instance, diabetes patients are admitted to the hospital with regularity, but almost never for diabetes itself.

"In reality, one in five people in a hospital bed usually has diabetes, but that’s not why they are there," Stone adds. Diabetics often have longer length of stay because they have poor healing, higher infection rates, and comorbidities associated with diabetes.

He points out that people with chronic diseases tend to have multiple problems, and sometimes the people treating them don’t have a total picture of what’s going on.

"One of the objects of disease management is to make sure the patients don’t fall into a gap between providers," Stone says.

Involving the patient’s primary care physician is an important component of a disease management program, points out Diane Gilworth, RN, MPH, who directs Harvard Vanguard’s congestive heart failure program.

"We’re not here to replace the primary care provider. We’re relieving them of the burden of frequent interface with patients," she says.

If you want to start a disease management program for your practice, your most important asset will be a physician who is willing to put the program together and talk it up among the staff, Lopez says.

Buy-in is a must

"Buy-in from your clinicians is essential for success," he adds. The programs at Harvard Vanguard have been developed by a small group of practitioners who are interested in those diseases.

"We haven’t purchased any programs. It’s not that we have excluded that possibility, but we’ve looked at our in-house capabilities and we feel we can do it on our own," Lopez says.

To develop the program, the Harvard Vanguard staff use guidelines from various sources, such as the Agency for Health Care Policy and Research, and draw on the resources of the specialists in the particular field. They also look to the chronic disease organizations, such as the American Diabetes Association and the American Heart Association, for other information on best practices.

In addition to staff to manage care and follow up with the patients, a successful disease management program needs a way to identify at-risk patients. You may be able to identify your at-risk patients by checking their medical records or by a system of alerts. For instance, when an asthma patient refills his or her inhaler frequently, the Harvard Vanguard Pharmacy alerts the asthma management program. Congestive heart failure patients are either referred to the program by a physician or identified while they are in the hospital.

You’ll also need a computerized medical records system to track your patients. At Harvard Vanguard, all documentation of patient care is entered into the system, including lab tests and prescriptions. The practice uses computers to track outcomes, document patient care, and identify patients who could benefit from disease management.

"It’s a very powerful way to be able to give feedback to the practicing clinicians and let them know how the patients are doing," Lopez says.

Next year’s high-cost chronic disease patient may be someone who isn’t showing many symptoms this year, Stone maintains. That’s why your disease management program should be geared to the entire population, not just patients with high cost or high acuity,

"The reason is that these diseases don’t go away. If you provide only acute intervention and don’t provide preventive interventions, a year from now you’ll have a whole new crop of high-cost patients," Stone adds.

A comprehensive disease management program for all patients reduces the complications associated with the natural progression of the disease and increases savings over time.