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Most managed care companies attempt to take the care of all chronic disease patients out of specialists’ hands and put it into the hands of PCPs, says Edward F. Philbin, MD, a cardiologist who practices at the Henry Ford Hospital in Detroit. But heart failure may be a unique type of chronic disease that represents a trend in the other direction, he says. There is growing evidence that disease and case management are viable strategies for delivering good CHF care, improving outcomes, and saving money. And some companies are coming to the conclusion that specialized heart failure clinics are a viable strategy.
Philbin, the lead author of the Chest study (see cover story), says he and his colleagues did another study on 43,000 patients where they found that managed care CHF patients received better care for heart failure and at a lower cost than nonmanaged care CHF patients.
"Managed care sees primary care doctors as costing less money," says Santosh G. Menon, MD, a cardiologist in the division of cardiology at the University of Kentucky in Lexington. "But I’m not so sure that CHF treatment costs less with a primary care doctor. It’s never been proven, and in fact, the long-term costs may be more."
Philbin’s study showed that heart failure patients’ initial treatment in the hospital is more costly when cardiologists do the treating. But once the patients have the right diagnostic tests, get started on the most efficacious drugs, and receive lifestyle and diet counseling by specialists, they may not need to be re-hospitalized as much, saving money in the long run.
"Leading managed care organizations should be experimenting with PCP education, including the use of guidelines and audits, incentives for PCPs to obtain cardiology consultations, and the use of specialty clinics devoted to CHF," says generalist Elgin K. Kennedy, MD, of Hillsborough, CA. He says the allure of cost-effectiveness and quality improvement is undeniable. But Kennedy adds that he doubts that the majority of managed care companies will make very many changes until such time as there is substantial proof that such changes will be truly cost-effective as opposed to just providing somewhat better quality.
[See the next issue of CHF Disease Management for new evidence suggesting that specialized outpatient care by clinics devoted to CHF treatment may foster better practice patterns and patient care.]