Plan carefully to ensure DM programs will succeed

Contracting with vendors may be to your advantage

When it comes to disease management programs, Kathy Cartelli, director of disease management for PacifiCare Health Systems Inc. recommends hiring experts.

"We put a lot of thought behind the pros and cons of doing it ourselves vs. contracting with vendors. We decided to go with people who have already developed the expertise rather than handling it ourselves," Cartelli says.

An analysis of their patients and claims data indicated that hiring specialists in fields such as oncology and neonatology along with the physicians to support the program would not be cost-effective, she adds.

In addition, like other entities in the health care industry, PacifiCare has faced a nursing shortage in many states where it provides coverage and foresaw the difficulty of finding enough staff to support the program.

"The vendors have large staffs, including the medical directors, nurses, and others who have expertise in each particular disease," Cartelli says.

When insurers develop their own disease management programs, they have to design comprehensive data systems and workflow management systems to do the job well, she says.

When the programs are outsourced, if you don’t get the performance you are looking for, you can always choose another vendor, Cartelli points out.

Doing the homework

Before choosing vendors for their program, the PacifiCare team went to industry meetings to learn about disease management programs and talked to representatives from other health plans to find out their experiences with various vendors.

"We would typically invite three or four vendors with expertise in a particular disease to come in and talk to us about what they could do. If they could meet what we were looking for, we would narrow it down from there," Cartelli says.

Before signing the contract, the PacifiCare representatives conducted a thorough investigation of each vendor, including making site visits, checking references, and studying each company’s financial statements.

Here are some other ways to ensure that your disease management program will work:

  • Decide on specific goals for the program before you talk with vendors.

    "Each organization the vendor contracts with may have different goals. That’s why they need precise information about the type of program you’re looking for," Cartelli says.

    If you know what you want to accomplish, you can set your expectations and the vendor will know in advance what it has to do to meet them, she adds.

  • Include performance metrics. The vendor needs a way to show if the program is successful.
  • Track both financial and outcomes data.

    Cartelli suggests including measure such as clinical indicators, utilization data, and member satisfaction information.