DM and Chronic Care(Part 1 of 2)

Is disease management the future of health care or a fad past its prime?

Clinicians see DM as good medicine but are wary

Disease management (DM) gets lot of press these days. At best, it combines a number of powerful tools into a pattern of integrated care, especially for the chronically ill. In its less savory form, it channels cash to groups that, some believe, already take more than their share. If used as intended, it’s unlikely to reduce costs, at least within the next quarter or even the next year, according to clinicians such as Thomas Bodenheimer, MD, a general internist and professor at the University of California at San Francisco’s School of Medicine. "It’s wishful thinking that disease management is going to save a lot of money for anyone, except perhaps in managing congestive heart failure," he contends. "With diabetes, osteoporosis, and depression, we will not save money in the short term. That’s why some people say disease management is going down in popularity already."

Still, we’d best not dismiss it, cautions Bodenheimer. "Quality people should be very interested in it. We need better chronic disease care. Quality improvement often deals with acute things like drug errors — and that’s a terrible problem to be sure. But every day, year after year, diabetics are running around with high blood sugars. It’s a silent problem that doesn’t show up on the quality assurance charts. But eventually, it shows up as severe complications."

Basically, DM is nothing new. It’s a comprehensive, coordinated package of care, especially critical to those suffering from chronic illnesses. The definition, for this discussion, is drawn from a recent article by two experts (David Bernard, MD, and Maulik Joshi, MHSA) who also shared insights with QI/TQM:

"Health and disease management may be defined as a clinical improvement process aimed at ensuring that the best practices known to medical science are incorporated with minimal variation over the entire continuum of care."1

DM relies heavily on information systems to identify people who use a lot of services. Case management also does that to a certain extent, says Janice Schriefer, RN, MSN, MBA, clinical systems improvement specialist at Spectrum Health in Grand Rapids, MI. The difference lies in the focus, however. "Case management deals with individual patients, while disease management deals with patient populations," she explains. (For a picture of how DM relates to the continuum of care, see "Health Care Clinical Management Tools," p. 3.)

One example of using different focuses: using a database to sort patients with high service utilization. A case management emphasis would use cost to select individuals who incur high dollar expenditures. A DM focus would use disease groupings to select populations with potentially high utilization diseases such as asthma, chronic obstructive pulmonary disease, congestive heart failure, or diabetes.

It may come as a surprise to hear that DM and cost reduction strategies might not be compatible. For that reason, David Shulkin, chairman and CEO of DoctorQuality.com, advises that "organizations must fit their disease management goals into their strategic business decisions from the planning stage forward."

Bernard, professor of medicine at the Univer-sity of Pennsylvania School of Medicine in Philadelphia, calls DM "the ultimate promise of managed care — an amalgam of all the strategies developed over the past few years. It defines the best way to treat chronic diseases and puts the systems in place to provide that care. And it doesn’t come cheap."

Nor is it a guarantee of short-term cost reduction. Bernard says he has learned from firsthand experience as former senior medical director of Health and Disease Management at the University of Pennsylvania Health System in Philadelphia. He explains that the system developed financial problems in applying its DM programs and has been forced to scale them back. "When managed care was introduced, it was supposed to improve quality and preventive care." But the management of care has gradually slipped out of clinicians’ hands, he contends. "Disease management returns the decision process to the clinician."

DM also thrives in organizations that deliver the whole continuum of care. While, we typically think of moving the patient from point A to point B for services, a good DM program moves the services around the patient, according to Joshi, former senior director of quality at the University of Pennsylvania Health System. (See "Disease Management Models," at left.)

There is no question among experts who spoke with QI/TQM that DM is good medicine. It also requires high maintenance and a lot of resources. Here are a few of the ways it can run aground:

1. If the emphasis is on program development to the neglect of continuous program improvement.

2. If you count on the primary care physician to carry the ball. Forget it, warns Bodenheimer, "The poor, beleaguered primary care physician doesn’t have the time! We’re too besieged with acute problems. We need somebody else to do it."

3. If it’s treated as a static program, instead of an integrated process. "You need to have all the pieces in place and use them as a continuum," Joshi says. "The whole system has to restructure itself to make DM work. It’s a fundamental change in the approach to care." He offers the example of regular foot exams for diabetics. Instead of directing all the change efforts to the doctor, the person who escorts patients to the exam room should ask them to remove their shoes and socks for a foot exam.

4. If it’s mistaken for a short-term cost reduction strategy. "The right question to ask is, Do you achieve the quality of care you set out to achieve?’ not whether you get a return on the investment," Bernard states. Indeed, it may well increase costs for a while. "When physicians talk about disease management for osteoporosis, they say screening should start with teenagers. There’s still plenty of time to do something about bone loss. If we do that, however, we will not see a return until the teens reach age 65 when women develop spine problems and fractures from osteoporosis."

But screening is expensive, and managed care companies will not agree to it for all teenagers, he observes. "So, doctors follow the managed care guidelines and screen when women reach their 40s or 50s. By then, they have less time to prevent the problems. And, even then, the payoff is 20 years down the road."

5. If organizations fail to work out equitable distribution of monies. The best DM delivery teams consist of specialists and primary care clinicians to ensure treatment of all the patient’s health care problems. "But that doesn’t always happen," Schriefer says. "There’s the professional envy over payment differences between primary care physicians and specialists." In capitation plans, she notes, there’s also the question of which fund a fee should come out of when primary care physicians and specialists are involved in a case. "Even though disease management prevents admissions, physicians can’t help but wonder whether it will pay off in this year’s contract."

6. If it is turned over to a "carve-out" entity. Patients do not respond as well to educational brochures or phone calls from a third-party monitoring organization, Bodenheimer says. "It has to be someone who is where the patient is, like the office nurse or the health educator who sits down and teaches them about their diet or exercise or medications. For example, we have too many rheumatoid arthritis patients who have not been taught to use exercise as part of their home care."

7. If DM is launched from the wrong base. "There’s no way every private medical practice can do it," Bodenheimer says. They don’t have the resources. Exceptions include large independent practice organizations such as Lovelace Health Systems in New Mexico and the Kaiser Health Plan, he adds. They have the resources and both systems implement the concept well. Even if DM does fade into oblivion as the fad of the 1990s, Bodenheimer observes, it’s still good medicine.

From its earliest days, DM was ripe for conflict of interest and misunderstanding. He explains that it was promoted by pharmaceutical companies in the early 1990s. They provided databases, and epidemiological and patient education tools to help providers implement DM programs.

"But the ethical problems in those arrangements arise when another drug company comes out with a better drug," Schriefer notes. "Clinicians need to be committed to switching to a better drug if or when one comes along, even if it’s made by a different manufacturer."

Bodenheimer sees additional problems with the carve-out approach. He laid them out in a recent article: "Commercial programs must obtain contracts from employers and managed care organizations to make a profit. To get contracts, they must save money for their clients. To save money, they must focus on the patients who are at highest risk, who have the most expensive health care needs, and who are motivated to follow medical recommendations."2

The large numbers of patients with low risk or less motivation are of little interest to commercial programs, he notes. Risk-stratifying information systems enable commercial DM programs to select the patients for whom health care costs can be reduced. That leaves the care of less motivated patients to comprehensive health care organizations and primary care physicians, he contends — and he argues for keeping DM under the auspices of health care delivery systems and affiliated providers.

Bernard shares that opinion. Describing DM as the "ultimate way to improve the care of patients," he decries its misuse — limiting it to areas where it has quick returns, typically in congestive heart failure and asthma. "It’s a tragedy when it’s used in that way," he states. "The reality is that you do not make more money by taking good care of patients." (For a description of a DM initiative for diabetic care, see QI/TQM, October 1999, p. 121.)

(Next month, Part Two in this series looks at chronic care as the biggest challenge to face the health care industry in the next 10 years: designing services for the 100 million people who have chronic conditions, a number that is destined to balloon to 135 million by 2020.)

References

1. Joshi MS, Bernard DB. Classic CQI integrated with comprehensive disease management as a model for performance improvement. Jt Comm J Qual Improv 1999; 25(8):383-395.

2. Bodenheimer T. Sounding board: Disease management — promises and pitfalls. N Engl J Med 1999; 340(15):1,202-1,205.

Need More Information?

For implementation of DM programs, contact:

- Janice Schriefer, Clinical Systems Improvement Specialist, Spectrum Health, (no street address is necessary) Grand Rapids, MI 49503. Telephone: (616) 391-2974. E-mail: janice.schriefer@ spectrum-health.org. Alternate e-mail: jschrief@ umich.edu.

- Maulik Joshi. E-mail: MaulikJoshi@Health Executive.com.

- David Bernard, MD. Telephone: (215) 772-0257.

- David Shulkin, MD. DoctorQuality.com (a best-practice implementation site for physicians and others in the health care professions), 944 Merion Square Road, Gladwyne, PA 19035. Web site: www.doctorquality.com.

For insights on handling disease management data, see:

- Liang MH, Shadick N. Feasibility and utility of adding disease-specific outcome measures to administrative databases to improve disease management. Ann Intern Med 1997; 127:739-742.

For information about disease management and case management software, contact:

- ThinkMed, 312 E. Wisconsin Ave., Suite 314, Milwaukee, WI 53202. Telephone: (414) 287-6000. Web site: www.thinkmed.com.