Disease management

DM Program Parts for Sale (Some Assembly Required)

Some HMOs have created a third way when confronted with the question of building or buying a disease management program.

"Some combination of both" is often perceived as the first refuge of the wishy-washy, the answer given when bets are hedged. But when "some combination of both" is how many health care experts respond to the build-it-or-buy-it question regarding disease management programs, suddenly it gains stature.

Build a disease management program or buy from a vendor? In many instances, hybrid programs are the answer.

"It's really very complex," says Lorraine Donagher, product manager for disease management at ConnectiCare, an independent practice association-model HMO covering about 200,000 members. "A combination of building, buying and partnering — including partnering with physician groups, hospitals, pharmaceutical companies, home-health agencies and other medical associations — results in innovative programs. Elements of two of ConnectiCare's disease management programs, for asthma and congestive heart failure, have involved a vendor relationship."

Donagher cites the plethora of information in trade, medical and even consumer publications regarding the numerous academic centers, pharmaceutical manufacturers, information technology companies and independent disease management companies that claim proficiency in developing and implementing disease management programs. "However, I have not found one vendor that can provide a comprehensive, all- inclusive disease management program and that understands the particular nuances of the managed care industry."

In some instances, the weed growing throughout the managed care garden — insufficient information technology — forces health plans to take this third route. While they want to keep their hands firmly on the reins of any disease management program, they lack access to a database that will point them to at-risk members and help them collect outcomes information. In the past, some plans answered the build-it-or-buy-it question by not answering. But delay is becoming less of an option. With the ever-increasing emphasis on outcomes, plans must begin to show numbers to back up stated concerns about quality of care.

One of the problems with weighing the build-it-or-buy-it question is that people often mean different things when discussing disease management, says John Wallendjack, M.D., vice president of HealthAmerica, a for-profit HMO covering about 560,000 members in Pennsylvania, Ohio and West Virginia. "The term has been overused by a lot of people," says Wallendjack. "I'm very skeptical. I'm willing to look at a program if it fits into the utilization process that we've already developed. The plans that are using disease case management want to see demonstrated outcomes and, basically, you don't leave that to the vendor."

Especially when obtaining such information means interacting with patients. An InterStudy report says that one of the more noteworthy recent occurrences in disease management involves using patient satisfaction measures as an evaluative tool. "Patient satisfaction is the area that HMOs measured the second most frequently in 1997, yet it was the seventh most frequently reported evaluation tool in 1996," states InterStudy Competitive Edge (7.2): HMO Disease Management Initiatives.

Many levels

Paula Filler, vice president in charge of product development at the Sachs Group, a company that provides business advice to hospitals, group practices and managed care organizations, says what you need to buy from vendors will become evident as you construct a program. "Maybe you already have a pretty good program but there's just one component that you need, such as home health care. A disease management program can have many levels."

Many plan executives don't decide on a hybrid program until after they're well into the construction phase, says Harry L. Leider, M.D., vice president of health services and corporate medical director at HealthNet, with 450,000 members in Kansas and Missouri.

Plans often wind up turning to vendors for help in dealing with some unforeseen problem. "Most people underestimate how complex it is to build a disease management program," Leider says. "There are components that are not easy to obtain, like how to reach people who normally don't come in to doctors' offices. It can take a year to build a disease management program from scratch."

Thomas Morrow, M.D., vice president and medical director of One Health Plan of Georgia, a for-profit preferred provider organization and HMO covering about 280,000 lives, says there are three general types of disease management programs.

The first involves sending educational material to patients. "There's no audit to see if the patient actually needs it," Morrow says. The second type is more interactive and usually involves installation of a 24-hour hot line to nurse practitioners. The educational material sent out with this type includes surveys that help care providers pinpoint at-risk members. "This second type is very popular," Morrow says. "More involvement, such as regularly calling to encourage compliance with the physician's orders, might also be needed in specific cases. Coordinating the advanced education with the primary care or specialty care physician is a necessity to avoid alienating the physician."

The third type is a program in which a medical group or hospital plays an active role. "The best example of this is a staff-model HMO," says Morrow.

Buying pieces

PCS Health Systems, the giant pharmacy benefit manager owned by Eli Lilly and Co., supplies educational material used in One Health Plan's diabetes and asthma management efforts. Morrow uses the educational material as components of programs he's constructed.

"We bought the material from PCS, but we're doing the case management," says Morrow, adding that another component PCS supplies is an updated database. "PCS has drug sales data and one of the big things you need to do is identify the patients. Most HMOs don't have modern ways to mail things to members."

One Health Plan supplies nurses to make follow-up calls to ascertain how much at-risk patients know about their condition. The health plan also sponsors one-day educational seminars at hospitals for those patients.

Wallendjack of HealthAmerica says his plan hired Cardiac Solutions to provide a 24-hour hot line for members with congestive heart failure. Why did he buy that component? "It is the kind of partnership that allows us to maintain shared responsibilities, and make the best use of our existing resources," he says.

Plans should make sure they're guaranteed a certain level of satisfaction. For instance, Wallendjack says he recently canceled a deal with a vendor who offered a prenatal care program. "The vendor just never measured up," Wallendjack says. "Now, we're doing it internally." The sticking point was the lack of response to a questionnaire the vendor sent out to identify at-risk patients. The form asked, among other things, if the woman smoked, took drugs or had ever given birth preterm. The response rate was 20 percent, says Wallendjack.

Since taking over, HealthAmerica gets an 80-percent response on a similar survey. Data like that help when health plans seek accreditation from the National Committee for Quality Assurance. "Health plans want to demonstrate to the marketplace that they're doing something about quality," Wallendjack says. "The National Committee for Quality Assurance is saying, 'Show us what you've done in the last year to improve the quality of care for your membership,' and this is something plans can show NCQA."

Morrow chimes in that, based on his experience as an NCQA surveyor, just saying you have a disease management program isn't enough. He's seen many home-grown disease management programs that did not produce desired results. "It is incredibly difficult to develop, warehouse, mail and update educational material," says Morrow.

Whole or part?

Hold everything, says Peter Smith, CEO of Ralin Medical, the company that owns Cardiac Solutions. Smith strongly contends that HMOs typically do not buy only components of disease management programs — they buy the entire thing. He describes the HealthAmerica-Cardiac Solutions relationship as an anomaly. "Almost every one of our 30 clients uses the full range of our services," says Smith. "At the end of the day, we find very few customers wanting to buy just pieces of the program." Smith does acknowledge that many HMOs keep a firm grip on how the program operates. He likes the analogy of someone who hires a plumber and then hovers about while the job is being done.

But Jeffrey Kaplan, M.D., chief medical information officer for Heritage NY Medical Group, a management services organization in Garden City, N.Y., that covers about 30,000 patients, contends that hybrids predominate.

"Even with large carriers, disease management is not a niche business yet," Kaplan says. "They do not have specialized expertise and so, therefore, disease management programs are often outsourced. Health plan executives don't want to lose control and they don't want to buy something off the shelf. There's also the fear that there's going to be some pressure down the line from the pharmacy companies to sell some of their products"--pressure, Kaplan says, that must be mollified with ground rules or eliminated by using nothing more from pharmaceutical companies than educational materials.

Wallendjack echoes that concern. "Somehow, I have a hard time unlinking the fact that many disease management programs were created by pharmaceutical companies from the business of selling pharmaceutical products," he says.

The Disease Management Strategic Research Study & Resource Guide foresees a "major shift in the future toward reliance upon external vendors/providers to assist [emphasis added] in the development of disease management programs. We believe this shift will be caused by growing resource constraints."

Exactly, says Donagher of ConnectiCare. "The debate over the value or cost-effectiveness of disease management programs is almost nonexistent," she says. "The real question is the value of partnering, purchasing or developing the components of a disease management program."

When to build, when to buy

Creating a hybrid disease management program is often the final stage of a process that began with the question: Is it better to build or to buy? The answer, in many instances, has been to buy some components and construct others. Still, many other health plans have rejected this third way, focusing on the original two choices.

Harry L. Leider, M.D., vice president of health services and corporate medical director at HealthNet, has seen the pros and cons of both methods up close.

Several years ago, Leider worked for Harvard Community Health Plan (now Harvard Pilgrim Health Care) as that not-for-profit HMO built disease management programs. One of the big benefits of constructing a program from scratch is that you have a better chance of obtaining physician buy-in — a must for viable disease management.

"Building it — if it works, and that's a big if — allows you to capture all the economic savings," says Leider.

He got a chance to buy a program recently for HealthNet, which he joined in the spring of 1995. HealthNet purchased a high-risk maternity program from Matria Healthcare. The program was launched in January, so it's still too early to measure success. Next up, an asthma program slated to go on line this month.

"The big appeal of buying is you can deal with somebody who has a track record for success," says Leider. "Sometimes, you can get a brand name. Implementation can come pretty quickly — between ninety and one hundred days. Buying it also means that your partner can share some of the risk. You can construct a contract where the cost of the program can be paid from the savings realized."

Leider says the build-it-or-buy-it question needs to be answered on a case-by-case basis. But basically, bigger HMOs might want to consider building their own. He hasn't worked out a cutoff — how many covered lives separate build from buy territory. "When you're talking about tens of thousands of people, it may not be worth it to build."

Al Lewis, president of the Disease Management Purchasing Consortium, says staff-model HMOs and integrated delivery systems possess the resources to build programs. "You need to have top management buy-in and a budget," says Lewis. "What doesn't work is trying to build a disease management program with existing resources. That happens all the time."

When executives tell Lewis they're tempted to build instead of buy because their plans possess the "medical competency" to do so, Lewis responds that outsourcing work properly is also a competency.

"You could also develop the competency to 'absolutely, positively' deliver your own mail overnight but there's an expert out there who already has the competency to do that," Lewis says. "People say to me 'But we're so good at medical management.' You may be good at medical management for the 95 percent of the people who are well but you can no more take care of the other 5 percent than McDonald's can sell fine French cuisine."

For serious diseases, health plans should begin by assuming they are going to buy programs, says Lewis. "Programs that involve serious applications, that are a lot of help for a few people, that have very high claims — those are usually a buy, specifically because you can get deals that guarantee first-year savings."

If the disease affects a large number of members and you don't have to see savings immediately, that could be a build. Lewis says obesity and hypertension are diseases for which you might build programs. For cancer and congestive heart failure, you'd buy.

This is a flexible demarcation, he says. "Asthma is an exception because even though it affects a lot of members and claims cost are relatively low, several vendors guarantee first-year savings."

And Lewis likes to tell the story of one large for-profit HMO that includes a nephrologist among its medical directors. This official recently spearheaded a drive to create a DM program for end-stage renal disease. "It's probably the best end-stage renal disease program I've ever seen," says Lewis, who quickly cautions that the presence of the nephrologist is the reason it works.

"Boys and girls, don't try this at home."

Frank Diamond
Senior Editor

Needed: Strategies To Get Physicians To 'Buy in' to Disease Management

Physicians have to accept the programs for them to work. But most doctors need to be convinced that they're worthwhile.

When Ellen Hughes, M.D., enrolled one of her patients in a program to help people with heart disease learn how to take better care of themselves, it was a well thought-out move. The patient was motivated and ready to jettison bad habits to improve her condition, and the regimen met Hughes's criteria for disease management. The program, based on research by heart-care pioneer Dean Ornish, M.D., offered in-depth nutritional training, group therapy and consultation with the referring doctor. "I got a sense that it was a service and that they were not trying to take the patient away from me," says the internist.

Eight months later, the patient takes less medication and, generally, has a better life, says Hughes, who is also an associate professor of medicine at the University of California at San Francisco. "The program taught the patient a lot of skills that I would not have had the time or expertise to help her gain."

The Heart Disease Reversal Program of the University of California San Francisco Medical Center and California Pacific Medical Center uses a mix of classes, counseling and monitoring to help heart disease patients get their illness under control. It is one of a growing number of disease management programs health plans across the country are using to orchestrate care for patients with chronic high-risk and high-cost diseases.

Disease management programs vary greatly in their efforts to improve quality while reducing costs. Many people believe — and are beginning to prove through outcome studies — that providing patients with preventive education and care improves their lives as well as reduces the chance that complications or setbacks will land them in expensive emergency room or inpatient settings.

Physicians play a critical role, often working with case managers and following specific guidelines under the assumption that using proven approaches will reduce the occurrence of complications and the need for costly urgent care.

That means that the programs have another thing in common: the need for willing physician participation — their "buy-in," as some call it. For the programs to work, physicians have to accept them. But, like Hughes, most physicians need to be convinced that the programs are worthwhile.

Physician concerns

Planning a strategy to win physician support is one of the first steps in setting up a disease management program, and a consensus is building in the industry on which techniques work. Many health system and health plan executives, as well as companies that sell disease management services, are coming to the same conclusion — for physicians to participate enthusiastically in a disease management program, they have to be involved in the program's design. Moreover, the program must offer physicians something in return — perhaps better care for patients, tools to improve their practices or financial rewards.

Physicians believe it's their job to manage diseases and therefore don't always see the need for disease management programs, says Harry L. Leider, M.D., vice president of health services and corporate medical director at HealthNet, an insurer with several types of managed care products covering about 450,000 patients in Kansas and Missouri.

Physicians sometimes think that when an organization proposes a program, it is telling them they are not doing a good job. "But what we are really saying in managed care is that we want to create programs to help physicians manage patients when they are not in physician offices, and to identify patients who need more care from physicians."

Craig Samitt, M.D., medical director of Harvard Vanguard Medical Associates at Kenmore, a multispecialty group practice in Boston, says lagging physician buy-in is the biggest obstacle to implementing disease management programs.

Harvard Vanguard has two such programs and would like physicians to refer more patients to them, he says. "Not all physicians have come to see that preventive care and management of populations are effective ways to provide care. Many still remain in the model of managing episodic care, so they may not see the value in education-focused, prevention-focused disease management programs."

Doctors are skeptical because they question everything about managed care, says Thomas Morrow, M.D., vice president and medical director of One Health Plan of Georgia. "Physicians don't believe in disease management. They think it is being thrust at them by managed care companies. They think it is strictly a cost-cutting measure." Disease management is a way to give managed care a higher level of control over utilization and cost by reducing demand, but in a way that benefits patients. Morrow continues, "At this point, the medical delivery system is basically going to have to do a better job of caring for patients. Disease management programs provide a mechanism to assist physicians in this challenge."

Still, physicians are concerned that disease management programs won't be flexible enough to recognize each patient as an individual, and fear that they are intended to reduce the amount of physician care, particularly by specialists. Yet most disease management programs are designed to help primary care physicians treat patients, not to supplant them.

Steven Leichter, M.D., an endocrinologist in Columbus, Ga., has worked in various roles in the design and implementation of disease management programs. But he worries that too often, programs are set up to replace physician services. "Many of these packages are sold to managed care companies with the notion that they will function and provide benefits to the managed care company in lieu of what the physician does," he says. "In my area of disease, for example, many disease management packages are sold to managed care plans with the suggestion that if you do this, you don't have to depend on the specialist. If you buy this program, just roll it into what your primary care physician does, and that will be good enough."

Specialists obviously are going to protest something like that, Leichter says. "Anybody developing a program needs to keep in mind that to avoid a backlash from physicians, the disease management package cannot compete with physician services."

Better ideas

Good programs, however, support-- rather than replace — physician services, so physicians need to keep an open mind when evaluating them, says Al Lewis, executive director of the Disease Management Purchasing Consortium in Boston, which works with HMOs to select, implement and troubleshoot disease management programs.

Many physician concerns about disease management are based on old practices. Vendors used to come in with their own networks of physicians to treat enrolled patients, and some early programs were wrapped around efforts to sell specific drugs. "It really has changed," says Lewis. "Most of those programs are gone now."

Resistance to the improved programs of today probably stems from lack of knowledge, Lewis suggests. "Competent, ethical physicians would not decline a program that results in better health for their patients, better information and no cost, which is what most of these programs offer." So educating physicians on disease management is the first step to winning them over.

For example, when Cardiac Solutions, a Buffalo Grove, Ill.-based company that offers disease management programs, signs a new contract with a health plan to manage patients with congestive heart failure, one of the first things employees do is set up meetings between members of the company's clinical staff and the health plan's cardiologists and primary care physicians, says Gene Miller, executive vice president at Cardiac Solutions. The goal is to explain that Cardiac Solutions' program of patient education, monitoring and home care is based on medical evidence and that it works.

At HealthNet, every disease management program has an advisory board of respected specialists and primary care physicians, Leider says. The health plan consults the physicians and educates them about disease management concepts and practices. A benefit, Leider says, is that the physicians on the boards often become champions of the programs and help win the support of their peers. HealthNet's approach reiterates a key point in obtaining physician buy-in: the need to encourage physicians to help develop the programs.

That worked for New York-based NYLCare Health Plans, which had two cardiologists help design a program to care for patients with congestive heart failure. "Their involvement was an important aspect of the product that made it much more readily acceptable to the participating physicians," says John Roglieri, M.D., corporate medical director at NYLCare.

The health plan worked with Stuart Disease Management Services to create and implement the program. Getting physicians involved was something the vendor highly recommended.

"We encourage plans to do a kind of grass-roots development of the guidelines so that there is buy-in at the local or regional level," says Kevin R. Karwath, group director of consulting at SDMS. "If these folks feel they have contributed to it, they are more likely to implement it and comply with it."

Another factor is that NYLCare's program, which focuses on patient education and telemonitoring and asks physicians to follow guidelines developed from national standards, really works. A study of 149 patients in the disease management program found that it reduces admissions, readmissions and lengths of stay significantly for those with congestive heart failure. That's enough to get physicians excited about participating, Roglieri says. He advises organizations to select illnesses for their first disease management programs for which the potential for improvement is high and the benefit of intervention has been proven through research.

Success breeds success

Once a program has been successful in one market, physicians in another may be more willing to participate, says John Wallendjack, M.D., HealthAmerica's vice president of medical affairs. The insurer offers its physicians access to Cardiac Solutions' heart disease program. The vendor's success in the Philadelphia area helped overcome even Wallendjack's skepticism.

The program makes good medical sense, so physicians have referred about 100 patients to it in just the last few months, he says. Physicians try it and like it, and they tell their peers. "It's contagious," he says.

Physicians get excited about improving the quality of medical care, NYLCare's Roglieri says, "But it gets even better if there's something in it for them, like free telephone calls to their patients every week with advice to them as to what's going on."

John Byrnes, senior vice president for performance improvement and innovation at Saint Francis Health System in Tulsa, Okla., had been working in the disease management field for several years before joining Saint Francis in December to launch a series of programs. Much of his effort over the years has been focused on physician participation. The bottom line, he says, is that disease management programs have to make physicians' jobs easier.

One way to do that is to turn guidelines into tools physicians can use in their practices, he says. For example, organizations can track how physicians are treating diabetic patients and then give them lists of patients who need certain tests or have missed follow-up appointments.

"It gives physicians a chance to get everyone in their practice caught up to what needs to be done at that time," Byrnes says. "If they wanted that kind of information several years ago, they would have had to review 100 charts. Now the disease management department can provide it. It's useful, and they can act on it immediately."

Once physicians see how disease management programs help them in their practices, enthusiasm gains momentum, Byrnes finds. He can't keep up with requests for disease management programs.

"The physicians here have been watching the progress of several systems throughout the country and really don't need to be convinced," he says. "Instead it's, 'How quickly can we get these things built and put into place?'"

MargaretAnn Cross is freelance writer based in Allentown, Pa.. She specializes in health care.


Physicians often need incentives to accept disease management programs

One way to get physicians to accept disease management programs with enthusiasm is to offer them economic incentives.

Many physicians are at risk for some amount of hospital care for their patients, so if an organization provides a disease management program that guarantees reduced hospital stays, physicians will benefit and be more likely to participate, says Al Lewis, executive director of the Disease Management Purchasing Consortium in Boston. Lewis works with 19 health plans, assisting them in identifying, selecting and contracting for disease management programs.

At HealthNet, which operates in Missouri and Kansas, affiliated practices that assume risk realize savings when hospital care is reduced through disease management initiatives, says Harry L. Leider, M.D., vice president of health services and corporate medical director. And it pays physicians an honorarium for helping to develop disease management programs.

It also may begin to pay physicians an annual case management fee for patients enrolled in these programs, to cover the time they spend communicating with program staff, Leider says.

"It takes time to talk to a case manager or go over a care plan," Leider says, "and some physicians are concerned that they are not being compensated for that effort. Successful disease management programs need to address that."

MargaretAnn Cross

Employers Interested In Disease Management — If It Brings a Return

Is there a concept in health care that has taken root and blossomed so fast as disease management? One that has captured the imagination and attention of the employers who pay for most of the nation's health care? Data collected last year by the National Managed Health Care Congress and Migliara/Kaplan Associates indicate that employers are aware of the possibilities that disease management offers, and are highly interested in participating, although there may be a slight lessening of interest compared with 1996. The mean of responses to the question, "How important is disease management on a disease-specific basis?" (scale 1—5) was 4.2 in 1996 and 4.0 last year, below pharmacy benefit (4.3) and drug/mental health care (4.2). Still, employers are busy contracting with vendors and health plans, and even growing their own programs. The full report, the 2nd Annual Disease Management Strategic Research Study and Resource Guide, will be published this month by the Disease Management Society and its parent organization, NMHCC, both of Waltham, Mass., (781) 663-6554.

One Health System's Approach To Disease Management

For New Mexico's Lovelace Health Systems, a fortuitous partnership with a disease management vendor has made it feasible to develop programs in 17 clinical areas without crippling costs.

High-profile activities are nothing new at New Mexico's Lovelace Health Systems. The multifaceted organization, which grew out of a Mayo Clinic-style group practice founded in 1922, developed and performed the clinical examinations given the first Americans in space, the Mercury astronauts.

But Lovelace's first forays into disease management were more a coalescing of parts than a single dramatic launch. For example, there was a practice guidelines committee in the late 1980s, recalls internist Harold Sunderman, M.D., a participant. And that committee got a lot of flak.

"When we sent guidelines around, we got comments like, 'This is cookbook medicine!'"

Adds Sunderman: "Through the years, I think physicians have realized that everybody has a 'cookbook.' It's just that for many it's in their heads. Maybe some cookbooks are out of date."

A coordinated approach

The years have changed things at Lovelace in other ways, too. When John Lucas, M.D., M.P.H., became the system's chief medical officer in 1992, he led efforts to coordinate what had previously been piecemeal initiatives. Three clinical areas — birth, pediatric asthma and diabetes — were examined to see how patients might be better handled, and outcomes improved, by looking at the whole stream of patient care in an integrated way, making the best use of facilities and talent.

Unfortunately, Lovelace's ambitions outreached its pocketbook. Big savings sometimes reaped by early disease management initiatives in less mature markets weren't available, because New Mexico had already learned a thing or two about managed care, and costs had come down.

The solution came in the form of a partnership. Kalamazoo, Mich.-based Greenstone Health Care Solutions, a wholly-owned subsidiary of the pharmaceutical manufacturer Pharmacia and Upjohn, wanted to market disease management programs and had capital, but didn't yet have the programs themselves. Lovelace had the expertise to develop the programs, but not the resources to fund the process. It was a natural match.

The health system created Lovelace Healthcare Innovations, a wholly-owned subsidiary of the Lovelace Clinic Foundation, to work with Greenstone to develop disease management programs that could later be sold to clients nationwide.

"We became what we call the living laboratory," says John Byrnes, M.D., LHI's CEO.

Though it is owned by a drug company, he says, Greenstone takes an approach different from the "value-added" disease management programs many manufacturers offer as marketing pieces to encourage use of their products.

"They told us from the start, 'We want you to develop the programs you need in your system. And we actually want you to do areas where we don't have products, because we want to show the market that we really are different," recalls Byrnes.

Today's disease management program at LHI goes by the somewhat ironic name "Episodes of Care." "We define an episode as all the care that is provided to a patient with a particular condition over a defined period of time, wherever the patient is in the health system," says Sunderman, who serves as LHI's medical director for clinical process improvement.

So far, the original three areas of clinical focus have grown to 17. In choosing subjects for disease management programs, LHI looks for conditions that offer opportunities to improve clinical outcomes, costs or quality of life. Even if an intervention is both financially prudent and clinically successful, Sunderman points out, "if the patient's quality of life wasn't what it could have been during the process, you haven't accomplished what you want." But he stresses that a program need not save money if it achieves significant improvements in the other two areas.

To create one of its programs, LHI looks at a given clinical condition — say, diabetes — and puts together a team comprising a primary care physician, a specialist physician in the area in question — an endocrinologist, for diabetes — and other relevant professionals, such as nurse-educators, clinic nurses and pharmacists.

"We sit down and say, 'OK, somebody gets diagnosed with diabetes. First, do we have guidelines on making diagnoses? Can we put a patient education program together? Which medications are best? What is the overall glycohemoglobin level of the patients in the system? Are patients getting annual eye exams?"

These data are collected and fed back to physicians in computer-printout form. "Here's the average glycohemoglobin level in your population of diabetics," Sunderman says a physician may be told. "And here are the averages for your clinic and for the entire system. And if you're doing great, that's wonderful. But here's a list of 15 diabetic patients of yours whose glycohemoglobin levels aren't well-controlled. Maybe you want to consider whether these patients have been to diabetes education recently, or whether perhaps they've not been filling prescriptions."

Not every innovation is rocket science. Asked why their rate of examining diabetic patients' feet was so low, physicians said many of their patients were elderly, and the time it took them to remove their shoes and socks took a big chunk out of a 15-minute physical.

Says Sunderman: "We went to the medical assistants who conduct patients into examining rooms and explained, 'You have an important role to play in the care of diabetics. Tell them when you put them in the room to take their shoes and socks off, so that when the physicians walk in they'll see bare feet.'"

Generally, LHI's disease management programs make medication-related decisions only by drug category, leaving it to the pharmacy and therapeutics committee to control specific choices for the formulary. So there is still a role for Lovelace to show a preference for specific medications based on discount deals it has struck with the manufacturers.

LHI's disease management initiatives depend vitally on implementation. "If you don't have the heart and mind of the provider," says Sunderman, "your program is dead in the water."

The biggest lesson Lovelace has learned from its disease management experience? "Watch the complexity of what you're asking the provider to do," he says.

For example, an otherwise superb program for attention-deficit hyperactivity disorder required primary care physicians to do a one-hour initial evaluation of every patient suspected of ADHD. Family physicians balked: "How can I meet my production quota if I book someone for an hour and risk having him be a no-show?" To remedy the problem, the implementation council is experimenting with an evaluation form it will ask parents and teachers to fill out about children with suspected ADHD. At an initial 15-minute appointment, parents will be given a package with a checklist of things to do — including filling out the new forms. A 30-minute follow-up appointment six weeks later will be cancelled unless the forms have been mailed in.

17 areas targeted by Lovelace

Disease management programs in varying states of implementation in the "Episodes of Care" program at Lovelace Health Systems cover these 17 areas:

  1. pediatric asthma
  2. birth
  3. diabetes
  4. depression
  5. attention-deficit hyperactivity disorder
  6. pneumonia
  7. hyperlipidemia
  8. breast cancer
  9. adult asthma
  10. anticoagulation
  11. spine care
  12. hypertension
  13. prostate cancer
  14. colorectal cancer
  15. stroke
  16. coronary artery disease
  17. congestive heart failure

Disease Management Gains a Degree of Respectability

Not too long ago, disease management was viewed with widespread suspicion. But the evidence mounts that well-designed programs make medical sense and can help patients as well as the bottom line.

Let's say you're a managed care executive trying to sell physicians on the idea that disease management is a good thing, for both them and their patients. Well, meet Terry Bennett, M.D., M.P.H., a 59-year-old Rochester, N.H., solo general practitioner and self-described "dinosaur." He could be your toughest customer. Maybe even your nightmare customer.

Disdain comes close to describing Bennett's view of you and most managed care organizations. As far as he's concerned, most HMOs approach doctors with one goal in mind, which is "to maximize their profits." He has, to be sure, many managed care enrollees in his 10,000-patient practice, but he says, "We batter the HMOs, so they leave us in peace." And his opinion of disease management? "It implies, by and large, a plan done for financial reasons that does not make any sense."

But get Bennett talking about 100-bed Frisbie Memorial Hospital, which is also in Rochester, and he will tell you how the quality assurance committee discovered that most of the hospital's congestive heart failure patients were not getting their weight checked regularly. Of course, gaining weight is a telltale sign that a congestive heart failure patient is retaining fluids and thus may need his or her medication adjusted. So Frisbie established a simple, straightforward protocol for regular bedside weight checks of congestive heart failure patients, according to Bennett. Sounds like something out of a disease management program, doesn't it?

Or get him talking about Tufts Health Plan, a not-for-profit HMO in Waltham, Mass. Tufts, he says, deserves an "A+" for the way it has approached Frisbie, cultivating good will with a small contract that paid for a review of hospital practices, identifying outliers and the like. But, you ask, isn't that disease management? No, says Bennett. "That is patient management."

Just a euphemism?

Bennett himself may be something of an outlier on the spectrum of physician opinion, but his views nonetheless signal some of the problems that proponents of disease management face. For people suspicious of managed care (especially in its for-profit manifestation), disease management is just a gussied-up term for denying services and limiting access to doctors. Say "disease management" and their heads dance with visions of drive-through mastectomies and gag rules.

A 1991 study for Pfizer Inc. by the Boston Consulting Group, a management consulting firm, is often credited with creating disease management. Therefore, for people suspicious of pharmaceutical industry intentions, disease management is little more than a way for drug makers to repackage educational materials and proactive prescription utilization programs.

Even where there isn't suspicion, there is often confusion about exactly what disease management means. The goal of disease management is clear enough (and just about impossible to quarrel with) — namely, to coordinate and manage the care of patients throughout the course of their disease. But as is so often the case, the devil of high-minded aspirations is in the details of their execution.

For Allan Khoury, M.D., the Cleveland-based associate medical director for medical informatics at Kaiser Permanente of Ohio, a computerized set of practice guidelines and reminders for physicians is the sine qua non of the whole field. "I think the most important component of disease management is guideline compliance," says Khoury.

"The guidelines may be the beginning," concedes Andrew E. Barrer, Ph.D., president of Physician Disease Management in Washington, D.C., "but how do you get to the end, where guidelines are being followed?" Barrer, whose company does outcomes research and provides case management services to physician groups, payers and pharmaceutical companies, emphasizes the importance of measuring outcomes and sees a key place for case management. Barbara Turner, M.D., a primary care physician and health outcomes researcher at Thomas Jefferson University in Philadelphia, sees disease management as a way for specialty physicians to "carve out" the care of patients by disease specialty, which in her opinion risks leaving primary care physicians out of the picture.

Disease management "is something that has been evolving, and what you think it is just depends on your slant on it. A rose is a rose is a rose, but none of them smell alike," says Thomas James III, M.D., medical director for Alternative Health Delivery System in Louisville, Ky.

Yet despite the suspicions, and perhaps because the eye of the beholder largely determines exactly what it entails, disease management is fast becoming as much a part of American health care as managed care itself. In a survey of 85 large employers and 15 disease management program vendors commissioned last year by the Disease Management Society, 94 percent predicted greater utilization of and influence for disease management programs. On a disease-by-disease basis, 80 percent said they had, or were planning to start, programs for diabetes and asthma; 60 percent were at one of those stages for breast cancer and 50 percent for depression. Sixty percent said they had operational programs for women with high-risk pregnancies. Still, for many of these organizations, disease management is still very much unexplored territory. Most of the existing programs have been in place two years or less.

The survey also found that most disease management is home-grown: 80 percent of the current programs at managed care organizations were developed in-house. But the organizations also reported expectations of greater reliance on outside vendors in the future.

Physician groups, hospitals positioned as "centers of excellence" in a disease area and companies devoted to disease management are all jockeying for position — and dollars — in the growing disease management market. More than 1,700 people attended the first meeting of The Disease Management Congress last year in Washington, D.C., and "exhibition floor space sold out three months before we thought it would," says Laurie Jackman DiModica, membership director of the society. These days, for every skeptical Terry Bennett, there is at least one Andrew Barrer arguing that disease management is the wave of the future in American health care.

Boomers: older, sicker, costlier

"Disease management is not depersonalizing at all," says Barrer. "To the contrary, disease management is a way to personalize health care more than ever. The old system was looking at disease only. It was event-centered. Now we look at care management as being patient-centered."

Though the initial impetus for disease management came from pharmaceutical companies worried about selling to managed care organizations, larger forces are at play that explain disease management's surging popularity. Demographics is one. The U.S. population is getting more and more top-heavy with the elderly, and although some recent research demonstrated gains in "compressing the morbidity" of the elderly, the basic equation holds: More old people = more chronic disease = more health care expense.

A widely cited paper in the Nov. 13, 1996, edition of the Journal of the American Medical Association on the cost and prevalence of chronic diseases reported that in 1987, when roughly one of every eight Americans was over 65, more than 45 percent of noninstitutionalized people of all ages had one or more chronic diseases and that their direct health care costs accounted for three-quarters of the country's direct health care expenditures, or $272 billion. By 2030, the JAMA paper said, when the baby boom is in its golden (a.k.a. sicker) years, one of every five Americans will be 65 or older, 148 million will have a chronic disease and their health care bill will reach $798 billion. No one is going to alter the demographic tide, so clearly the best ways to derail the projections are to keep fewer people from getting chronic diseases and to make treatment of chronic disease less expensive. Disease management partisans say that is what it's all about.

At a more philosophical level, some argue that organizing health care delivery and financing along disease management lines is simply the best fit for most of what modern medicine does, which is not so much to rid a person of a disease as to favorably alter its course and stave off death. Insulin is frequently cited as an example. It does not cure diabetes but treats one of its manifestations — namely, hyperglycemia.

Chemotherapy for cancer and bypass surgery for coronary artery disease can be viewed in the same way. This line of thinking says that it is 20th-century medicine's success, in a sense, that has added the "chronic" to "disease." Disease management is just the health care system's way of catching up.

Clamor for information

But there are much more immediate reasons that disease management is now being pushed into the spotlight. Managed care organizations have become especially interested in it as they scramble for ways to cut costs and increase profits or revenues. Certainly the bloom is off the rose of wellness programs: Too often the financial payback on a wellness program is uncertain.

Increasingly, says DiModica, managed care organizations are living by the so-called 80-20 rule: 80 percent of health-care costs tend to come from 20 percent of patients, so that 20 percent is where the attention should focus.

She notes that when there is too much variation in how people with a particular disease are treated, then developing a rational, coordinated system can help an organization bring the costly extremes back into line and perhaps alter the 80-20 rule to its advantage. Asthma is a good example. It has been a favorite target of disease managers partly because it is one of the most com- mon chronic diseases in the working-age population generally covered by HMOs (the same is true of diabetes). But also, historically, there have been wide variations in the hospitalization and emergency room utilization rates of asthma patients. Obviously, if a managed care organization can define a standard of care for asthma patients that keeps those folks out of the hospital and away from the emergency room, it is money ahead.

The booming market for Medicare HMOs is another reason managed care organizations are jumping on the disease management bandwagon. Given the expected flood into Medicare risk plans in the coming years, it is not the least bit surprising that 70 percent of the managed care organizations surveyed by the Disease Management Society reported that they have, or are planning to have, a congestive heart failure management program. Congestive heart failure is common — in fact, it is the most common cause of hospitalization for Americans 65 or over — and expensive — it costs Medicare over $5 billion a year. Moreover, there is still a lot of judgment involved in treatment of CHF, as doctors must chose from an array of drugs.

James, at Alternative Health in Louisville, says don't underestimate the influence of the National Committee for Quality Assurance on the behavior of managed care organizations. And though NCQA doesn't explicitly require disease management for certification, it does want managed care organizations to have some proof that they are working to improve the health of their population. "That," he says, "just about cries out, 'Show me your disease management program.'"

In Barrer's opinion, NCQA requirements for patient satisfaction and outcomes measurement have also whetted the appetite for disease management. "The risk takers have to be concerned not only about costs, but also about quality," he says. "In the 'old' days of managed care, it was purely cost reduction."

Disease management is also becoming more accepted by physicians because they are the ones doing it. And they are doing it because an increasing number of them are assuming, happily or not, some of the the insurance risk of covering patients. Capitation gives the physician much the same incentive to reduce costs, often by keeping patients out of the hospital, as the managed care organization receiving the fixed monthly premium.

"I have been to conferences where the presenters say that the physicians are clamoring for information about practice guidelines and disease management programs because they believe that it can help them better manage patients and finances," says Di- Modica. But some physicians (or the companies that employ or contract with them) are actually seeking out risk in the form of so-called "carve-outs" whereby both the care and the risk for a certain category of patients are assumed.

There is a lot of news in disease management circles these days about carve-outs for AIDS patients, for example. Though Barrer is the first to admit that the "science of costing out AIDS care is not very good," he says that if physicians were to seek an AIDS carve-out contract with, for example, Oxford Health Plan, they would use disease management to give them a sense of where they stand (how many patients, how sick they are, projections about their care and its cost) and how to operate (case management, patient education programs, outcomes data).

Information explosion

Finally, disease management has come into its own for the same trite, but true, reason any enterprise dependent on information has grown: the computer network. Khoury says the whole system of practice guidelines and rapid reminders to physicians about adhering to those guidelines "would be very difficult to do without computers." And of course, outcomes measurement, which Barrer and many others say is key to a successful disease management program, would be impossible without all the data collecting and processing powers of contemporary computer systems.

Proof in the pudding

There is still a lot of wiggle room left in the definition of disease management, and a whole lot of active debate and discussion about how disease management ought be measured. The result is that it is hard to get anyone to say flat out, "Yes, disease management works." DiModica's tentativeness about a broad-brush statement is fairly typical. "The results for disease management are there, but the successes are anecdotal," she says. The anecdotes are nonetheless beginning to pile up, and one apparent reason disease management is taking off is that it does seem to be working fairly well.

In many cases, the imprimatur of academic research and government reports has been one key to disease management efforts. It both gives managed care organizations some outside information to go on and immediately wins the program some credibility with physicians and patients. So, for example, Khoury cited a study published in the New England Journal of Medicine on Sept. 14, 1994, to make a disease management case for annual flu shots for the elderly. Undertaken at the Veterans Administration hospital in Minneapolis, the study found that annual flu immunization not only cut the rate of hospitalization for pneumonia, influenza and congestive heart failure, but also resulted in a cumulative saving of $5 million.

Many of the guidelines Khoury uses at Kaiser Permanente were developed from the federal government's Healthy People 2000 recommendations for health promotion and disease prevention. "These are not radical things we are doing," he says.

James says the 1991 National Institutes of Health consensus panel on asthma treatment, which was revised this spring, was the wellspring for the asthma disease management program at Alternative Health, and the same can be said of asthma management programs throughout the country. Similarly, the NIH-sponsored Diabetes Control and Complications Trial has been hugely influential both in making a strong case for comprehensive diabetes management (the study has shown a 50- to 75-percent net reduction in retinopathy, nephropathy and neuropathy and a $4 billion cost saving) and in showing what diabetes management should involve (frequent glucose monitoring and flexible adjustment of insulin dose).

Theory and practice

But the direction that a well-designed study can provide is one thing. Actually getting there is another. Proponents of disease management say their programs are producing real-world results. Cardiologist Randall Williams at Evanston Hospital in Evanston, Ill., launched a program for congestive heart failure patients in October 1995. It zeroes in on quickly identifying appropriate patients, educating them and tracking their compliance with medications. Williams's program keeps a close tab on ambulatory patients; he has them calling in every day with their symptoms and their weight.

A high proportion of patients on ACE inhibitors is widely considered one sign of a good congestive heart failure program; Williams says 90 percent of the patients in his program are on these drugs. He also says the proportion of patients who have had an ejection fraction measured in the last six months is "way up."

Williams says successful disease management depends on tight reins — "You don't solve the problem unless you control, manage and integrate all the clinical resources across the full continuum of care" — and physician involvement.

"If you don't have the doctors directly involved, you aren't going to get very far."

Cutting hospital days

As with most other conditions, the component of congestive heart failure treatment that accelerates cost most dramatically is hospitalization. Williams says his program has cut the length of stay for Evanston Hospital congestive heart failure patients from an average of 6.2 days to 4 and, even more impressively, cut the 30-day readmission rate from 19 percent to 2.6 percent.

Evanston Hospital bought his program for less than $250,000, he says, and recouped its investment in less than six months (because congestive heart failure patients are covered by Medicare and most cardiologists are still paid on a fee-for-service basis, the financial risk for congestive heart failure patients tends to fall on the hospital, explains Williams, though that could change with the advent of Medicare HMOs).

At Alternative Health, James says that since a "baby watch" program for risky pregnancies was started four years ago, the rate of low-birth- weight babies (2,500 grams or less) has dropped from 2.5 percent to 0.5 percent. The core of the program is a nurse contacting pregnant women over the phone. James is candid. He says he cannot prove that the baby watch program had anything to do with the lower number of low-birthweight babies. Also, the actual number of babies involved is quite small; the 2-percentage-point decrease reflects roughly 45 fewer low-birthweight babies per year. But it is still improvement, especially given the serious, lifetime consequences of low birth weight.

James also says the more recently developed asthma management program has also produced good results. A before-and-after comparison of 211 patients in the active disease management program showed, over six months, a drop in emergency room admissions from 75 to 34 and a drop in inpatient admissions from 31 to 6.

Both Williams and James stress how important it is to get physicians behind a disease management program. "If doctors don't feel that one alternative is better than another, you can have the best guidelines around, but they are just not going to use them," says Williams.

As someone brought into a cardiology group a couple of years ago specifically to set up a disease management program, Williams hasn't had to proselytize his colleagues. James, however, working for a managed care organization, goes to innumerable committee meetings ("I've had more than my fair share of doughnuts," he says). "Physicians have to have a sense of ownership and buy-in" if a disease management program is to work. Otherwise, he adds, they will resent the effort as a managed care plan's obnoxious attempt to dictate their practice of medicine.

The patient factor

Patients also have to be sold on disease management if it is to work, James says. "Patients wonder, 'What in the world does the insurance company want to know all of this information for? All I want is for them to pay the bills,'" he says. Sensitive to the suspicions of patients, James says Alternative Health's asthma program uses a soft touch to encourage patients to participate. For example, he says, a nurse might visit a hospitalized asthmatic and say something like, "This is terrible, this asthma landing you in the hospital, and we have a program that could help you."

Where primary care fits in

All the indications are that disease management, in all of its various forms and manifestations, will continue to weave itself into the fabric of American medicine. Skeptics like Terry Bennett, who don't like or trust managed care organizations, will be hard to win over. If the programs improve patient health (or "make sense" in Bennett's terms) and prove they can do more than doctors' hands and save insurers money, maybe even the skeptics can be won over.

But there is also worry on the part of some primary care physicians, such as Barbara Turner, that disease management could become overly dominated by specialty groups. Taken too far, carved up by different specialists, disease management eventually could cause the kind of uncoordinated care problems it was designed to solve, she says.

"Many people have multiple diseases. Under fee-for-service medicine, they would almost literally wander from doctor to doctor," Turner says. "There was no coordination. I think for patients with complicated diseases, having a physician to coordinate care, to be the central repository of information, can make an enormous difference. If I send a patient with a pulmonary problem to a specialist, I may be the only person who knows that the prescribed medication is not good for that person's valvular disease."

Peter Wehrwein is a Boston-based health and science journalist and a senior writer at the Harvard School of Public Health.

Peter Wehrwein

Constructing Disease Management Programs

Formal disease management is one of the more vibrant areas of health care, with drug manufacturers, health plans and independent companies all greatly interested. Here's a plan for putting such a program together.

As the health care delivery market struggles to reform itself, size and efficiency become important issues for providers of care. Engaged in consolidation, the marketplace closely examines new models of delivery that offer increased efficiency and competitive advantage while maintaining or improving quality of care. In this milieu, the concept of disease state management (DSM) has attracted significant interest from drug manufacturers, pharmacy benefit managers (PBMs) and managed care organizations as a potential model to accomplish these goals.

Defining disease state management

Although a universally accepted definition is lacking, for this discussion, disease state management can be described as an integrated system of interventions, measurements and refinements of health care delivery designed to optimize clinical and economic outcomes within a specific population. It has been pointed out, however, that the term "disease state management" is not entirely correct since the patient, not the disease, is being managed. Although "population-based care" or "continuous health care improvement" are preferred by some, disease state management, or sometimes just disease management, prevails.

Properly designed, such a program relies on aggressive prevention of complications as well as treatment of chronic conditions. The program is created with a clear understanding of the natural course of a disease in a population and the effect of interventions at critical points to delay or prevent morbidity and mortality. DSM calls for a fundamental shift in the way health care is delivered, with both care and reimbursement based on a systems approach rather than the component approach that has been standard in the past.

When, as in traditional medicine, components of a disease are managed singly, providers and payers tend to address only what they are responsible for treating or reimbursing. The focus on treatment of acute medical problems rather than preventive care leads to a reimbursement system that favors expensive treatments in high-cost institutional settings over less expensive treatments in lower-cost community settings. Without an incentive to treat all aspects of the disease, health care is uncoordinated, wasteful and lacking in continuity.

Will our system of health care delivery be replaced with a more efficient, more effective health management system? Managed care organizations are introducing DSM because they manage large patient populations with a variety of health care needs, often under a capitated reimbursement program. Although they cannot provide direct treatment and do not directly "manage diseases," pharmaceutical companies, pharmacy benefit managers and disease state management companies are exploring partnerships to design and implement DSM programs. Two premises of such partnerships are that:

  • Combined and coordinated resources create synergy in managing disease; and
  • Aligned incentives are most effective in ensuring that the partners maintain a strong commitment to the program.

What, then, makes disease state management different from traditional utilization review? It's in the boundaries. Defining the risk as treating an entire disease, or even an entire class of drugs, shifts management focus away from components and toward systems, where there is greater potential for real savings and quality improvement. Accepting this change is one of the greatest challenges facing DSM program participants.

Can a managed care organization in such an arrangement really stabilize or reduce expenditures over entire therapeutic areas in which costs have been increasing? Results of pilot programs are just beginning to be disseminated, and early reports are promising. However, extensive reports of the success or failure of DSM programs will not be available for some time.

Drivers of DSM development

The major force behind the development of DSM probably has been employers' concern about health care expenditures. Cost-cutting has forced a closer look at health care service reimbursement and cost-effectiveness. Medical plan sponsors are calling for providers to account for the enormous costs. At the same time, it is becoming necessary for pharmaceutical manufacturers to demonstrate the value of their drugs in producing a therapeutic outcome, and pharmacists are beginning to demand reimbursement for cognitive services. Because past approaches to health care have been less than ideal, many believe the shift to a systems approach is necessary.

The team approach

While pharmaceuticals are an important component of disease state management, a disease cannot be managed through pharmaceutical care alone. Well-designed programs require the input and commitment of program administrators, health care providers, information managers, finance experts and patients. This is what each can contribute:

Program administrators

The people who run a health plan are the best source of information on organizational structure, goals and expectations, pay and incentive programs, and fiscal commitments to the disease management program. The success of such a program is strongly linked to the support it receives from the administration during its development and implementation.

Physicians

Traditional medical education provides a rigorous academic background followed by intensive experiential training to assure competency. The practicing physician's clinical experience and continuing medical education build on this, but at the same time, the system has produced significant variation in treating each disease.

In the DSM system, medicine will be required to undergo a basic shift in approach, as shown below.

Changing practice models will require development of dynamic practice guidelines rooted in outcomes measurements, along with physician behavior modification.

Medical specialists must collaborate in developing treatment guidelines, even where national guidelines or recommendations from panels of experts are available. Once guidelines are developed, physician education can be accomplished through training programs and, if necessary, one-on-one academic detailing.

Pharmacy benefit management programs have repeatedly proved that physicians will change behavior when shown objective measurements of their performance against established criteria in population-based prescribing, hospital admissions, use of ancillary services and other efficiency parameters.

Physicians as a group are not exempt from acting in their own financial interest, however. They may be moved toward optimal management, including use of practice guidelines, by appropriate economic incentives that involve risk-sharing. Combining these methods in a well-coordinated program should assist physicians to adapt.

Pharmacists

Academic and professional training in pharmacotherapeutics and pharmaceutical care empowers pharmacists to play a critical role in disease state management. Pharmacists in highly integrated managed care settings participate in formulary decisions, drug treatment protocols and critical pathway design. Other activities pharmacists can perform in a DSM program are listed above and to the right. Most of these activities involve education and monitoring, for which pharmacists are particularly well trained.

In developing a DSM program, one must often deal with an increase in budgeted pharmacy department costs, since expensive drug treatments sometimes replace hospital stays or surgeries that are more expensive. Drug use in disease state management programs therefore must be viewed in perspective, as an integral part of medical care instead of a separate cost in a component-managed system.

Information managers

Data analysis plays a critical role in designing and operating a DSM program. Baseline measurements are necessary for later comparisons to ascertain whether care has been improved and costs have been controlled.

Most information systems in health care plans cannot track care in the detail required for outcomes research, nor can they provide administrators with information for continuous DSM program improvement. Computerizing clinical data is critical in these programs, which usually have only claims data from billing systems.

Information managers help the planning team decide on data formats and definitions. They determine the usefulness of current information systems and also promote exchange of appropriate data elements among the partners.

Finance managers

The DSM team's finance experts must thoroughly analyze current costs of care, including the costs of failing to achieve intended outcomes and the predicted financial consequences of the DSM program.

In addition, this team is responsible for negotiating contracts among the disease state management partners, and for clarifying arrangements among them with regard to risk-sharing and capitation.

Patients

The potential for success is highest when the patient is on the management team, because an informed patient is better equipped to help manage his disease than an uninformed one. This involvement is especially important when patients consume significant acute care resources because of poor disease control. Patient education and intervention result in better understanding of the disease and greater rapport with medical caregivers; both are essential for patient participation in the management plan.

In the interest of conserving resources, education and intervention should be coordinated with health risk assessment (see "Goals for Patient Education," below). Education programs for mild or episodic asthma patients, for example, should be much less intensive than strategies for those with moderate or severe asthma. Severely ill patients with a history of extraordinary medical resource consumption should receive the most intensive education and intervention.

Measuring patients' expectations and satisfaction with care in a DSM program is important for continuously improving the program. Patients have a profound effect on their clinical outcomes, and should understand the responsibility they hold in managing their health. Now that we have better methods for measuring outcomes, patient satisfaction and quality-of-life improvement can be used in analyzing a DSM program.

Patients are beginning to gain more authority in judging the quality of their health care and demanding to know more about their medical conditions and treatment options. Ultimately, the patient is the consumer, and will demand satisfactory management of his disease.

Choosing diseases to manage

General criteria for selecting a disease to be intensely managed include:

  • High-prevalence chronic disease states;
  • High-dollar-volume or high-velocity drug use;
  • Potential for wide variation in treatment approach;
  • Potential for lifestyle modification to improve outcomes;
  • Therapies with many treatment options, and
  • Diseases with high risk of negative outcomes.

These criteria lead to a group of diseases that are often considered for management (see "Conditions Most Commonly Selected for Disease Management ").

Selecting partners

Managed care organizations usually lack resources in several areas necessary for developing and conducting disease state management programs. There is no shortage of professional organizations, educational institutions and for-profit companies willing to provide these resources; pharmaceutical manufacturers, PBMs and disease management companies frequently approach health care organizations with proposals.

The managed care organization itself, however, must have certain capabilities to be successful in a DSM partnership. The managed care organization should possess:

  • Cooperative medical providers. The plan should enjoy a good working relationship with its care providers, preferably with incentives that encourage them to provide cost-effective care and improve quality.
  • A computer system with accurate, detailed and summarized medical and pharmacy claims data for a period of at least 12 months. The plan should be willing to share demographic and specific enrollment data (such as details on the patient, the managed care plan, the PBM, the amount of copayment and the formulary) with its partners.
  • Willingness and ability to commit market share to a pharmaceutical partner, if applicable. A relatively closed formulary or portion of a formulary is useful. The partners should share in the benefits of expense reduction.
  • Willingness to conduct aggressive co-promotional programs with the partner.

Managed care organizations, PBMs, pharmaceutical companies and their subsidiaries are exploring different combinations to find the ones that will be most productive.

Capabilities that the pharmaceutical companies or their DSM subsidiaries can bring to the relationship because of their size, resources and experience include:

  • Determining the total cost of an untreated illness;
  • Determining the natural history of a disease and the cost of treatment;
  • Conducting outcomes research in the target population;
  • Designing patient education and compliance programs for a specific DSM program that might not even include drug use;
  • Providing expertise and manpower for developing and promoting professional education of DSM providers, and
  • Supplying providers and patients with education and communications materials.

The pharmaceutical benefit manager, a comparatively new player in health care delivery, can:

  • Collect and analyze data critical to DSM success, and
  • Select noncompliance and other drug use patterns for education programs.

Developing treatment guidelines

After choosing partners and doing a baseline analysis of current care, it is time to draft treatment guidelines (also known as clinical practice guidelines or practice parameters). Success here is possible only with the exhaustive collaboration of medical providers. Possibilities will vary with the disease, but some or all of the following are usually involved:

  • National expert panel recommendations, such as reports from the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure and the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults;
  • Independent clinical consultants on faculty at a school of medicine or pharmacy;
  • Consensus panels of national, local or plan-contracted therapeutics experts;
  • Pharmacists in the plan, and
  • Physicians in the plan.

Success in promoting these guidelines lies in combining the partners' personnel and other resources to communicate, educate and encourage physicians to participate. The ability to identify physicians who fail to comply with treatment guidelines is critical. Without it, the program will not be able to change physician behavior.

Aligning the incentives

When managed care organizations and potential partners design business agreements, three terms often appear: outcomes management, capitation and disease state management. The success of any of these activities can be traced to the concept of shared risk.

Many utilization management programs have failed in the past because the managed care organization objective of lower pharmaceutical cost often meant decreased sales for the partner that provided the drugs. Even where traditional utilization management programs were marginally successful in managing a single component of the costs, overall reduction of expenditures frequently remained elusive when costs ballooned in other areas.

Plans have traditionally relied on negotiation of component prices to reduce the whole expenditure. This strategy, even when employed skillfully, failed to recognize the other side of the expenditure equation, which could include over- utilization of resources. Thus,

Total Expenditure = Component Price * Utilization

In short, narrowed vendor margins were offset by increased sales and/or utilization.

The road to real expenditure reduction and quality improvement may be paved with partnerships to improve clinical and economic outcomes where success rewards all partners equitably.

In disease state management, the agreement must include at least these cost drivers:

  • All of the drugs or therapeutic classes of drugs that are specifically employed in the treatment of the specified disease;
  • All therapeutic devices and adjuncts to therapy;
  • All hospital days with ICD-9 discharge codes for the disease, and surrogate markers for the disease and its complications;
  • All emergency room visits coded for a particular diagnosis or complication, and
  • All laboratory and other diagnostic costs associated with the disease.

The agreement will cover other cost drivers that can be measured within the defined population — and are relevant. An office visit coded for asthma, even though measurable, costly to the physician and clinically significant, might not be financially relevant to the disease state management program in a system in which physicians are paid on a capitation basis.

These cost drivers are quantified by merging pharmacy and medical claims data. Managed care plans that are seriously attempting to manage care are already capturing medical encounter data in such a way that specific identification and quantification of these cost drivers is possible.

If components of disease state management are applied effectively, the expectation of clinical quality improvement and decreased overall cost through increased efficiency should be realized. It is reasonable to draw up a shared-risk agreement where the costs of data technology, physician services and patient education are put at risk against the realization of an expenditure goal.

If a target is met or exceeded, the providers of the education, intervention and data technology share in the benefit of expenditure reduction with the managed care organization.

Setting the target for expense reduction is a balancing act between the current cost of delivering care to the specific population and the estimated cost of developing and implementing ideal practice standards as they are embodied in guidelines.

The target can be determined by using a model incorporating known variables, such as:

  • Expected change in drug cost resulting from appropriate use as delineated by protocols;
  • Expected reduction of hospitalization resulting from program application;
  • Cost of an average hospital day associated with coding for the disease;
  • Expected decline in emergency room visits, and
  • Cost of the average emergency room visit associated with coding for the disease.

As greater experience is gained in the marketplace with such programs, targets will be readjusted. The partners may find themselves in a position to employ some benchmarking as well.

Measuring success

The primary measure of success for a disease management program is found in outcomes research. Well-designed studies are critical in documenting improvement in care, and include such indicators as clinical and economic outcomes and quality-of-life and patient satisfaction surveys. Performance can be compared to normative databases, allowing plans to take a look at their results in light of those achieved by other plans.

Successful disease state management will use continuous improvement programs to determine the ongoing changes necessary to provide the most cost-effective health care management.

Mary C. Gurnee, Pharm. D., writes frequently on pharmacy issues. Robert V. Da Silva is vice president, disease management, at MedImpact Pharmaceutical Management Inc., San Diego.

Fundamental shift in medical practice

Away from Toward
Reactive, experience-based, sickness-oriented approach Population-based, health risk management approach using evidence-based principles
Reliance on interventions that offer the possibility of benefit Reliance on interventions that offer evidence of benefit
Component cost control System cost control

Pharmacist activities in a DSM program

  • Patient education concerning drug use, especially in high-risk/high-use cases
  • Compliance education and monitoring for selected populations
  • Disease state monitoring (blood glucose, blood pressure, serum cholesterol, etc.)
  • General wellness education
  • Intervention with physicians to encourage drug protocol adherence

Goals for patient education

  • Promote understanding of the disease and coping strategies
  • Ensure that the primary care physician is kept informed
  • Teach techniques of monitoring progress of the disease and avoiding exacerbation
  • Involve patient in support groups or organizations that provide continuing education, counseling and fellowship
  • Encourage patient to make appropriate decisions regarding therapy

Conditions most commonly chosen for disease management

  • Asthma
  • Cardiovascular diseases
    • Coronary artery disease
    • Congestive heart failure
    • Angina
    • Lipid irregularity
  • Depressive disorders
  • Diabetes
  • Ambulatory infectious disease such as otitis media, urinary tract infection and community-acquired pneumonia
  • Pain
  • Upper gastrointestinal disease, including peptic ulcer disease and reflux esophagitis
  • Women's and children's health
Mary C. Gurnee, Pharm.D.
Robert V. Da Silva, M.S., R.Ph.
Cover Story

Can Health Plans Change Unhealthy Behavior?

Smoking, fat-filled diets, endless gazing at the tube — they're disastrous for health and bad for the bottom line. So physicians and managed care organizations are grappling with ways to put more life into the American life style.

Andrea Niemi was motivated, no question about that. Bothered by weight problems most of her life, the 46-year-old St. Paul, Minn., lawyer two years ago had joined a health club that was about six blocks from her home. She had gotten herself into the kind of five-, sometimes six-days-a-week work-out routine that exists for most of us only as last year's unfulfilled New Year's resolution. But for all her discipline and sweat, the five-foot, five-inch Niemi had lost just 15 of her 210 pounds. She was still keeping storehouses of lovely dark chocolate in her desk at work and still buying those tasty malted-milk balls at the candy store on the way back from the courthouse. "I had gotten the health club exercise part of it together. I just couldn't get the eating angle," says Niemi.

Then, about a year ago, Marcia Hayes entered the picture. For the first few months, they started out chatting once a week for about 20 minutes. Niemi says she used Hayes "to bounce ideas off, to encourage me, to tell me when I was just being wacko." And instead of beating up on herself all the time and expecting perfection, Niemi says Hayes has encouraged her to take a more forgiving, Rome-wasn't-built-in-a-day approach to shedding weight. Eating a low-calorie diet and working out regularly, Niemi says she was hungry all the time. Hayes's advice? "She said maybe you should eat something!" The chocolate in the desk is gone and after-court candy store detours have stopped. Niemi now weighs 165. As a bonus, she and Hayes have come to know each other pretty well over the past year — well enough to laugh at little in-jokes, says Niemi: "She has gotten to know me and my issues and my progress."

But Andrea Niemi has not laid eyes on Marcia Hayes, and maybe never will. Hayes is a dietitian for Niemi's health plan, HealthPartners, and all of her patient counseling for HealthPartners is done over the phone. Far from resenting the facelessness of their encounters, Niemi says the convenience, the regularity and the one-on-one attention make it the best weight loss program she's ever been involved in — and Niemi feels as if she had tried them all.

And it didn't cost Niemi a penny beyond her standard premium. "I tell people who have HealthPartners that it is a great deal. And it's free!" says Niemi.

Ounces of prevention

For more than 30 years now, the health and financial benefits of changing unhealthy behavior have been fairly obvious to physicians, health care providers, insurers and government officials. But the health care system's record on helping people like Niemi change their unhealthy ways is patchy at best, though some broad society-wide improvements are evident (see "Actually, We Are Living More Healthily," page 33). Mixed-up financial incentives, inattention to prevention by medical schools and a lack of motivation by patients have all gotten in the way. But with the evidence of the costs of changeable behavior so strong, the pressure on physicians, managed care organizations and the entire health care system to spend an ounce on prevention to save a pound of cure seems to be growing. The latest version of the Health Plan Employer Data and Information Set (HEDIS) measurements promulgated by the National Committee for Quality Assurance includes, for the first time, a measurement of how many smokers in a health plan were advised to quit by their physicians. The Health Care Financing Administration is considering a survey requirement that would, in essence, grade Medicare health plans on how well they keep members healthy.

"Physicians and health plans are going to be held increasingly accountable for outcomes," says Nancy Richardson, the vice president for business development for Healthtrac, a Menlo Park, Ca.-based company that sells self-care and health promotion counseling services. Richardson believes the trend will put some teeth into incentives to "do what is best for the patients and not just what costs less."

Truly embracing such an emphasis on behavior change would mean persuading physicians to view the practice of medicine in terms of populations instead of individual patients. Richard Thompson, M.D., director of preventive care at Group Health Cooperative of Puget Sound, says he wants the 680 doctors in the mixed-model HMO to start thinking of themselves as "practicing miniature public health." Through claims data analysis, physicians in health plans around the country are being told how their immunization and mammography rates stack up against their peers and against other standards. When it comes to influencing physicians, many health plans now seem to favor the the gentle written reminder. But they haven't forsworn the carrot or even the stick.

Besides influencing — even pressuring — their member physicians, managed care organizations are reacting to this heightened awareness about the connections between health and behavior by setting up telephone counseling services, offering self-care programs and literature and zeroing in on their members who are most at risk and most willing to change. To some extent, the old-style wellness program of giving everyone a discount on a health club membership or sending everyone nutrition advice is falling out of favor. "We have the found that the best thing to do is to target our investment and programs at the people who need and want the services, rather than sprinkling them across the whole population," says George Isham, M.D., medical director and chief health officer for HealthPartners in Minnesota. HealthPartners has beefed up its telephone counseling service so that it now handles 4,000 to 5,000 calls a month and employs the equivalent of 11 full-time dietitians and health educators.

Does this mean that managed care organizations will soon become behavior cops? Probably not, experts say. The evidence is still too blurry that interventions aimed at changing behaviors related to diet and exercise are effective. Health plans are moving cautiously, with smoking cessation programs leading the way.

"I think we mainly need to hold people responsible for their own behavior," says Robert Harmon, M.D., United HealthCare's national medical director. "But people need help. And a managed care organization needs to provide scientifically validated help so that people deal with their life style problems."

America's unhealthy ways

Whether through long-standing custom, bad habit, acquired addiction, simple carelessness or sometimes circumstances outside any one person's control, Americans routinely act with a kind of reckless disregard for their health. About one-third of adult Americans — 58 million people — are overweight. Six out of ten rarely or never exercise. One out of every four still lights up despite three decades of warnings that smoking causes lung cancer as well as a witch's brew of other diseases. Seat belt and child safety seat use is up, but by some estimates half of all Americans either ignore or don't correctly use car safety systems. And about 1.5 million are arrested each year for driving under the influence of alcohol. Others, obviously, elude arrest.

The American life style? Maybe it should be renamed the American disease-and-death style. Researchers have documented the havoc wrought by these behaviors in study after study. In 1993, William Foege, former head of the Centers for Disease Control and Prevention, and J. Michael McGinnis, head of the Office of Disease Prevention and Health Promotion in the U.S. Department of Health and Human Services, published a widely cited study in the Journal of American Medical Association about the "actual" causes of death (see chart at left). Instead of the usual groupings, such as heart disease and cancer, they used "external" (nongenetic) causes. Sifting through the medical literature, Foege and McGinnis calculated that roughly half of the 2.1 million deaths in the U.S. in 1990 were due to external causes. About four-fifths of those causes could be classified as behavioral: smoking, diet and activity level, alcohol, shootings, motor vehicle accidents and illicit use of drugs.

Perhaps to no one's surprise, tobacco use is deadliest of these behaviors. Foege and McGinnis figured tobacco use caused 400,000 American deaths, or 19 percent of the annual total. Meanwhile, the evidence mounts almost daily that inactivity and bad eating habits contribute to an enormous amount of illness and early death. The 1996 U.S. Preventive Services Task Force reported that physical activity and fitness reduce morbidity and mortality for six chronic conditions: coronary heart disease, hypertension, obesity, diabetes, osteoporosis and some mental disorders. Breast, prostate and colorectal cancer have all been linked to low activity levels. Just last month, Norwegian researchers published in The New England Journal of Medicine the results of a large prospective cohort study showing that women who exercise cut their breast cancer risk by 37 percent. Meanwhile, more and more connections are being made between specific dietary factors and cancer (see below).

The automobile is another American danger zone. Motor vehicle accidents are the leading cause of death among children and young adults, thus a leader in a statistic that many health policy makers believe is more revealing than simple death rates: years of life lost. Much of that highway carnage might be avoided if people wore lap and shoulder belts, which cut crash mortality rates in half. Drunken drivers are a public health disaster. In 1994, alcohol was involved in 41 percent of all traffic fatalities.

The dollar cost of all this unhealthy behavior can be sliced, diced, tallied and accounted for in dozens of ways. But the bottom line is always the same: Unhealthy behavior costs society a lot of money. Direct health care costs for smoking-related illness are over $50 billion per year. The annual tab for the country's drinking problems has been put at $70 billion (an estimate that includes lost productivity). The nation's cancer bill has also been estimated at $70 billion, and apparently much of that money could be saved if researchers are correct in their belief that two-thirds of cancer mortality is linked to modifiable behaviors such as smoking and diet. The National Safety Council estimated that in 1994 alone, motor vehicle accidents cost the country $169 billion, counting lost wages, medical expenses and administrative costs.

Put a different way, people who smoke and have lousy health habits end up spending more of the nation's medical dollar. The average lifetime medical cost in this country is an astounding $225,000 per person. Research has shown that medical costs for smokers, despite their shorter lives, are fully one-third higher than for nonsmokers. Health habits have been shown to be predictive of insurance claim costs. In one key study, the claims costs of people in the high-risk health habit group were eight times higher than people in the low-risk group.

Old dogs, new health tricks

Part of the problem with getting people to change their behavior is the problem with all delayed gratification: The effort is in the present tense, the benefit in the future. "It is hard to persuade a patient to do all of these things — and stop doing all of these things he enjoys doing now such as smoking, eating, being lazy — on the vague promise that maybe 10 to 20 years from now he won't have something happen to him. And it may not happen anyway," says H. Emerson Thomas, M.D., a Boston-based primary care physician who calls himself a "preventologist."

It is also a fallacy to picture all health-determining behavior as a matter of individual choice, argues Lauren A. Dame, a lawyer for the Washington, D.C.-based Public Citizen Health Research Group. In the United States and throughout the world, health and wealth march in virtual lock step: The richer you are, the better chance you have of a long and healthy life. Besides the obvious issue of more limited access to health care services, being poor brings with it a raft of conditions that are hostile to health: the neighborhood that is stressful, polluted and dangerous; the job that involves heavy lifting or working with dangerous chemicals; the store that sells junk food; the low self-esteem that feeds into drug abuse.

"There are life style choices that make a difference in health, but it is a smaller difference than we like to think," says Dame. "If poor people living near a toxic waste dump are unhealthy, it's not just because they don't go jogging every day."

Nor does society's effect on health-related behavior stop at the poverty line. Graham Colditz, a Harvard Medical School epidemiologist, has noted how contemporary American life steers people away from a simple, healthy activity that previous generations took for granted — walking. "The structure of our cities does not encourage any physical activity," he says. "While our grandparents walked to school and probably to work, we drive the car."

Even if patients were ready, able and willing to change their ways, the financial incentives can work against a health plan's investing much in prevention or behavior change. In many cases, says Thomas, "you have inexperienced, untrained physicians who don't have an incentive to do what they also have had little training to do," Thomas says.

For the managed care organization, prevention efforts pose what Helen Halpin Schauffler, an associate professor at the University of California-Berkeley School of Public Health, terms the "free rider" problem. A plan investing heavily in keeping people healthy may incur costs while never seeing benefits because the effects — avoiding serious disease and hospitalization — are not likely to show up until 10 or 20 years down the line, explains Schauffler. This is not true of all preventive services. Usually, childhood immunization is held out as an example of a preventive service with a quick payback in terms of avoided illness and medical cost. But particularly when it comes to modifiable behaviors that affect chronic disease, the benefits are so distal from the costs that the financial incentives are weakened.

Another difficulty is that prevention is not necessarily effective if the goal is reducing medical expenditures. Picking up a problem early through a screening test can result in years of fairly expensive treatment. In pure dollar terms, that cost will not necessarily be offset by the savings of avoided illness. A classic study in the mid-1970s showed how this worked for blood pressure screening. It is a cheap test, and medical treatment is often effective. But the savings generated by fewer blood pressure-related illnesses is not offset by the cost of years of medical treatment generated by the screening test.

"That is sort of a cynical notion — that if you don't get it back in dollars, why should anyone do it?" says Isham, at HealthPartners, noting that curative medicine is not held to that standard. Schauffler, pointing out that only 1 percent of the nation's health expenditures go to prevention, says, "Let's spend three percent and get healthier people. It's a no-brainer to me. But it is not a money-saver."

One of the impediments to efforts to change unhealthy behavior is lack of proof that physicians and other health care providers are very effective in this area.

So it is significant that the 1996 U.S. Preventive Services Task Force report echoes the original 1989 report's endorsement of smoking cessation programs. Given the fact that smoking is the most destructive changeable American health behavior, the unequivocal evidence that smoking cessation programs work is good news for anyone who wants doctors and managed care organizations to get more involved in keeping their patients healthy. The report recommends regular tobacco cessation counseling for all patients who use tobacco products. It also states that "a brief, unambiguous and informative statement on the need to stop using tobacco" is the most effective clinician message. Prescription of nicotine patches or gum is suggested as a way to ease withdrawal symptoms.

NCQA's new HEDIS measurement of how many physicians advised their smoking patients to quit obviously reflects the U.S. Preventive Services Task Force's recommendations and seems certain to spur managed care organizations to formulate better anti-smoking programs. Harmon, at United HealthCare, says that a program starting in July will include five telephone counseling sessions and discounts on nicotine patches and gum. But the jury is still out on how much of a difference smoking cessation programs can make. The most frequently cited study — a meta-analysis of 37 clinical trials — is now almost 10 years old. It found a modest 6 percent difference in quit rate between smokers in intervention programs and controls.

Nor is designing an effective program easy or cheap. Group Health Cooperative's "Free and Clear" program is often held up as a model of what a good smoking cessation program should be. Thompson has reported quit rates of about one in four. And rates of participation rose elevenfold when the smoking cessation program was made part of the HMO's standard benefits package in 1993.

The 1996 task force report also recommends that physicians counsel patients on dietary habits, activity levels and motor vehicle safety. But as the report made clear, these recommendations had more to do with the potential benefit than any solid evidence, based on clinical trials, that such counseling would work to change people's unhealthy ways.

Thompson is only slightly more sanguine. He says recent research has yielded some hopeful "glimmers" that physician counseling on nutrition might be effective. A study recently done at Group Health Cooperative showed that minimal nutritional counseling — basically, a physician handing out some literature — could result in small differences in dietary fat intake. But it was a small study with a very modest result. And when it comes to counseling patients on exercise, Thompson says, "The answers are just not there."

Researchers have been more successful in nailing down the effectiveness of physician intervention with problem drinkers, and in many ways task force recommendations on screening for drinkers parallel those made for counseling on tobacco use. In April, Wisconsin researchers published what they claimed was the first direct evidence that physician intervention with problem drinkers decreases alcohol use and utilization of health services. The intervention was pretty simple: two 10- to 15-minute counseling sessions by a physician using a scripted workbook. A year later, the 392 problem drinkers who had received the counseling were doing better on several problem drinking indices (binge drinking, recent excessive drinking, estimates of seven-day alcohol use). The counselees had also used the hospital less.

More counseling, less time

In theory, the spread of capitation should encourage behavior-focused preventive medicine. As Thomas points out, with capitation, "The message is that you don't get your rewards out of seeing sick patients and making them better. You get your rewards economically and professionally by keeping people well."

But capitation cuts both ways, Thomas adds. Counseling and educating patients are time-consuming, and capitation puts pressure on physicians to spend less, not more time, on each patient. "I used to schedule patient visits for 20 minutes," says Thomas. "We are now down to 15 minutes and we are looking at 10. And we are now considering reconfiguring our office so I no longer have a consulting room but exam cubicles instead, so I can pop in and move quickly."

While he admits that doctors can be a "little more slick in our operations," Thomas says there also comes a point where the "time provided is too little to accomplish the goal that is sought."

Capitation isn't the only way managed care organizations are prodding physicians to change. For the easy-to-measure, process-oriented preventive efforts, such as mammograms and immunizations, they are using claims data and other information to keep tabs on a doctor's performance, much as HEDIS does for the organization as a whole. Presumably, as smoking cessation and perhaps other behavioral change efforts become more a part of mainstream medical practice, physician performance in those areas will also be tallied. Thompson says Group Health Cooperative sends "clinical practice reports" to its staff doctors every three months that include information on immunization and mammography rates, as well as items more related to disease management. Harmon says United HealthCare sends "reminder letters" on immunization and mammography rates to physicians.

Thompson insists that the practice reports are less a report card than a communication in the spirit of "continuous quality improvement," though they do include benchmarks for comparison. Moreover, he says, Group Health Cooperative executives have discussed whether as much as 25 percent of a provider's salary should be contingent on meeting certain practice goals and patient satisfaction ratings. From fee-for-service to fee-for-time (i.e. salary), "what we are evolving toward is fee-for-outcome," says Thompson.

Having nurses or dietitians counsel patients on the telephone is cheaper than having physicians continually prod and cajole patients. The companies that are specializing in phone counseling and related services insist it can also be more effective. Ironically, the time pressure that managed care imposes on doctors may be part of the reason. "Physicians don't have the time, the tools or the training" to do such counseling well, says Richardson, the Healthtrac vice president.

Phone counseling programs have also increased their batting averages by being careful about whom they select, zeroing in on the people who are both most likely to change their health behaviors and at greatest risk of having serious health problems that could cost the health plan money.

In one project for a large New York City bank, Healthtrac used a familiar tool — the health risk questionnaire — and then combined the results with calculations about what conditions were going to be most expensive to treat in the next 12 months. HealthPartners' risk registry, which melds claims and patient survey data with biological information (weight, the results of lab tests), has much the same intent. Isham says physicians might use the risk registry to identify diabetics who need an exam or people for whom weight management might be a good idea. In many contexts, the distinction between health promotion through phone counseling programs and disease management does get fuzzy, especially when the "disease" is a condition such as obesity, which for many people is the consequence of behavior, namely poor diet and lack of activity.

The telephone's effectiveness

In any event, the phone has a lot of fans in managed care these days. United HealthCare's smoking cessation program is conducted over the phone. Group Health Cooperative's "Free and Clear" smoking cessation program includes both phone and group counseling. Thompson has reported only a slight advantage — 35 percent compared to 28 percent — in the quit rate between the folks enrolled in the group sessions (who may be more committed to begin with) and those who choose to be counseled by a faceless voice over the phone.

Jackie Labat, manager of the HealthPartners' phone line services where dietitian Marcia Hayes works, says regular calls from a managed care phone center are especially helpful for people in weight loss programs because research has shown that continual contact is necessary to sustain weight loss. To help keep the counseling personal, Labat says, the plan member deals with the same dietitian or health educator all the time.

Andrea Niemi stresses how important it was to her success that she had an ongoing relationship with Hayes. "You can build an excellent rapport over the phone," notes Labat. Besides, says she, many members seem to prefer the convenience and privacy that the phone affords: "You are talking from the comfort of your own home." Or in Niemi's case, from the privacy of her office.

Showing the money

Prevention advocates have long argued that prevention should be measured by the benefit it pays in health, not the costs it might avoid downstream. But for those who can't afford to embrace that view, cost remains a key ingredient in evaluating programs aimed at changing behavior.

That's one reason why the group with the biggest ultimate emphasis on health behavior change may be neither health plans nor physicians. It may be the employers and government agencies who buy the policies and pay most of the premiums. In California, the Pacific Business Group on Health (PBGH), which includes some of the largest companies in the area, used its premium-paying clout to negotiate standards for a model benefit plan — a model that deliberately emphasized provision of preventive services.

The business group also put some financial bite behind its wishes: 2 percent of the premiums paid to health plans was made contingent on meeting certain performance standards (based for the most part on NCQA's HEDIS indicators). According to a recent account of the PBGH experience written by Schauffler and her colleague Tracy Rodriguez, in 1995, $7 million was at stake, approximately 30 percent of which hinged on meeting prevention performance measures.

In some instances, government health officials are pushing managed care organizations to get more involved in a keep-people-healthy approach. Immunization rates, because they are easy to measure and their payback in avoided medical care costs is patently obvious, are a favorite first target. In Arizona, a joint state-managed care effort boosted the infant immunization rate from 50 percent in 1993 to 77 percent today, according to Doug Hirano, special assistant to director of the Arizona Department of Health Services. Because all of Arizona's Medicaid population belongs to managed care plans, Hirano said, state officials knew a successful immunization effort would have to involve the plans delivering health care and not just depend on the traditional county health departments. The effort is based on an agreement by health plans to report their immunization rates to state officials. The resulting plan-to-plan comparison engenders "a little friendly competition," says Hirano.

But he adds that "Diet and physical activity are little bit more nebulous and more difficult to track. It is not clear how much inactivity and poor nutrition are costing a managed care plan. That is more direct with immunization or asthma. For public health to work cooperatively and collaboratively with managed care," concludes Hirano, "we both need to have incentives."

Actual causes of death in the United States

Often, official clinical causes of death serve as euphemisms, masking real causes in the realm of behavior. Below, those deaths are unmasked.

SOURCE: "Actual Causes of Death in the United States," McGinnis and Foege, Journal of the American Medical Association, Nov. 10, 1993. Vol. 270, No 18: 2207–2211.

Diet and cancer risks

  • Fruits and vegetables may have a beneficial effect in reducing risk of several types of cancers. This finding is most firmly established for cancers of the lung, stomach, esophagus and larynx.
  • Legumes and grains (bread, pasta, cereal) may cut down the risk of stomach and pancreatic cancer.
  • Red meat consumption has been implicated as a risk factor for colorectal cancer.
  • High salt diets are a suspected cause of stomach cancer.
  • Saturated fat from animals has been linked to prostate cancer.

SOURCE: HARVARD REPORT ON CANCER PREVENTION, CANCER CAUSES & CONTROL, VOL.. 7, 1996.

Actually, we are living more healthily

If the studies are so persuasive, the statistics so chilling and the bills so high, why haven't Americans done more to change their unhealthy ways?

One answer is that many people have heeded the bombardment of health dos and don'ts or taken advantage of some useful coaching and counseling.

While heart disease remains the leading cause of death in this country, the age-adjusted heart disease death rate peaked in the early 1960s and has been dropping steadily ever since. Some large but undetermined portion of that decline has been caused by healthier life styles. In Healthy People 2000, government health officials chalked up the 40-percent decline in heart disease mortality in the 1970s to blood pressure screening and control, a decline in cigarette smoking and attention to blood cholesterol and dietary fat. Heart disease mortality continued to slide in the 1980s, and earlier this year Harvard researchers published a study in Journal of American Medical Association giving a greater share of the credit for the decline to treatment (coronary bypass, clot-busting drugs). Still, they figured about 25 percent of the heart disease mortality drop in the 1980s could be attributed to better diet and avoidance of smoking.

Cancer rates have also apparently started to decline, in part because Americans are heeding health messages. In December, the National Cancer Institute announced that the U.S. cancer death rate fell by nearly 3 percent between 1991 and 1995, the first sustained decline since the 1930s, when national record-keeping on overall cancer rates began. Better screening — thus early detection and more effective treatment — of cervical, breast and colorectal cancer explains some of this decline in American cancer mortality. But the cancer institute officials also said lower smoking rates were also a major force.

Motor vehicle-related crashes are the eighth leading cause of death in the country, but the annual number of fatalities has actually been dropping since the 1960s. Safety belt use is close to 70 percent and federal highway safety officials have estimated that seat belt laws save 3,600 lives each year. Child safety seats have saved an estimated 1,300 lives between 1982 and 1990 and motorcycle helmets saved 5,000 between 1984 and 1990, according to federal estimates.

Actually, it would be very strange if Americans hadn't started behaving in healthier ways in recent years, because they certainly seem to be living in a much more health-conscious society. Witness the emergence of the health food store, all the low- and no-fat foods on the supermarket shelves, the dozens of magazine articles promising 10 easy ways to achieve hard-as-rock abs. Where exhortation hasn't worked, the lawmakers have stepped in. Thus, better food labeling, the whole range of anti-smoking laws and ordinances and, of course, seat belt and motorcycle helmet laws.

No one could tune all of that out. Yet the amount of news media attention to health issues may also reflect just how hard it is to penetrate the individualistic, youth-oriented, live-forever American mind set. Also, for every "get healthy" message, there is a barrage of seductive advertising from people trying to sell the food, drink, tobacco and slothful pastimes (particularly television watching) that cause ill health.

Peter Wehrwein is a Boston-based health and science journalist and a senior writer at the Harvard School of Public Health.

Peter Wehrwein

The Role of Physicians In Disease Management

At its best, disease management is neither a turf protector for specialists nor a marketing vehicle for drug companies. It's a common-sense approach to unifying care for a condition, and it depends on primary care physicians.

For a moment, imagine health care providers as the members of a big-city orchestra. Primary care physicians, specialists, nurses and pharmacists don formal wear and hoist instruments to entertain concertgoers. When the conductor waves his baton, is the sound harmonious?

It wouldn't be, if the orchestra followed medicine's traditional pattern. The reality is that most physicians, whatever their specialty, are accustomed to doing "solos." The independence for which they're trained makes them resistant to orchestration.

That resistance is being challenged these days, and disease management is just one of a number of phenomena — like profiling, utilization review, practice mergers and proliferating HMO contracts — that are posing the challenge.

By now, most physicians have learned that the term disease management denotes a system of care for a particular condition such as asthma, diabetes or cholesterol that is intended to reduce costs and improve outcomes. But many have never knowingly encountered one, especially those who don't work in integrated delivery systems. Others view the concept with skepticism.

It's true that primary care physicians are sometimes excluded from disease management programs, partly because they have not taken the initiative to participate, partly because managed care organizations haven't properly defined their goals and partly because specialists are using the programs to recapture lost patients. But when it's implemented properly, disease management demands the same teamwork that's required of an 80-piece orchestra, and the sheet music calls for a prominent part for primary care.

Cooperation required

"Disease management means more teamwork between primary care physicians, subspecialists and nonphysician providers," says family physician Lee Sacks of Oak Brook, Ill., a member of the American Academy of Family Physicians' Commission on Health Care Services.

Theoretically, in a disease management program, health plans and physicians attempt to identify patients who would benefit most from intense prevention and treatment protocols. "Ten percent of the members often generate 50 percent of the health expenditures," explains Danny Mendelson, vice president of The Lewin Group of Fairfax, Va. "Target them and manage their disease and you'll get a lot of bang for your buck."

Because employers and patients disenroll so frequently, health plans tend to select diseases such as asthma that will show a quick return on investment. They shy away from treating conditions like osteoporosis that may not show any measurable benefits for 15 or 20 years.

In a disease management program, physicians typically follow practice guidelines and define a course of therapy. Management of hypertension, for instance, might include stress reduction, behavior modification, weight reduction and diet and antihypertensive drugs if none of the interventions succeed. The program may call for follow-up by a nurse or physician assistant to determine whether the patient is compliant and to discover whether he or she is encountering any problems. If complications arise, the patient might be referred to a specialist. The physician and the patient will both receive guidance from the disease management program, often stressing strict compliance with a particular drug or other therapy. The program may keep independent tabs on when prescriptions are filled, for example.

Typically in disease management, physicians follow practice guidelines and suggest a course of therapy. Management of hypertension, for instance, might include stress reduction, behavior modification, weight reduction and diet and antihypertensive drugs if none of the other interventions succeed. Then, in most cases, there will be follow-up by the physician's nurse or physician assistant to determine whether the patient is compliant and to discover whether he or she is encountering any problems. If complications arise, the patient might be referred to a specialist.

Yesterday's fragmented system of health care delivery was not conducive to disease management, says William Winkenwerder, M.D., M.B.A., vice president of primary care services at Emory University System of Health Care in Atlanta. "In fee-for-service there was a very limited role for primary care physicians," says Winkenwerder. "They basically treated the patients and then referred them and didn't have accountability for following them through the disease process." Now, he adds, capitation and integrated delivery systems have given physicians an opportunity to be paid for making sure the patient is getting the best care, even after he leaves the office.

As providers and payers become more integrated, disease management programs will become a routine part of medical practice. But first, managed care plans must embrace the philosophy of population-based care. "Disease management is one of several population-based approaches to medical care," says internist John Harris, a former medical director for Cigna and CaliforniaCare HMOs who resides in Tucson, Ariz. Public health initiatives such as immunization programs are yet another approach, he says.

Managed care plans care for large populations, and that's where much of the incentive to initiate disease management programs lies. But traditionally, physicians haven't cared for populations; they've cared for individuals who make up the populations, says Harris. "Physicians don't look at their 1,000 or so patients and ask, 'What can I do to make people better off?'"

Disease management requires physicians to think about patient care in a different way. As Harris explains, "These programs require outreach; they contemplate long-distance monitoring. Those are not tools that doctors have in their black bags." But as doctors begin to take more risk through capitation arrangements, their willingness to change their thinking may grow.

Where it started

Staff- and group-model HMOs were the first systems to develop disease management programs, but other plans are catching on, too. At the Mayo Clinic in Rochester, Minn., for instance, about 15 programs have been initiated and another 10 are in the works. Mayo, a regional care network of five hospitals and more than 40 delivery sites, uses a multi-step strategy. First it identifies diseases that have high prevalence and high cost. The programs aim at the most likely targets, such as asthma, diabetes, urinary tract infections, breast cancer, and lipid and hypertension screenings. Mayo's provider team analyzes hospital admission rates, lengths of stay, morbidity and mortality, emergency room visits, pharmacy use and office visits. Then the team devises a "best practices" strategy, which includes practice guidelines.

"We have found that disease management has helped improve communication and integration between the primary care physician and the specialist," says Robert Nesse, M.D., vice chairman of the Mayo Clinic's department of family medicine.

Nesse concedes that some plans have adopted systems that undermine a teamwork mentality. To manage patients with high-cost, chronic diseases, some managed care organizations wield a knife and "carve out" certain diseases to specialist groups, essentially cutting the primary care physician out of the loop. Typically, the specialist groups accept both financial risk and the responsibility for clinical and administrative management.

Plans contract with certain companies that have developed provider networks concentrating in one or two particular diseases. For example, Value Behavioral Health manages mental health; Salick Health Care, which is 50 percent owned by Zeneca Pharmaceuticals, focuses on oncology services, and there are specialty groups that focus on allergies, AIDS, cardiovascular conditions and others.

Family physician Sacks, president of Advocate Health Partners, a contracting and care management organization for 150,000 enrollees affiliated with Advocate Health Care, has noticed that some HMOs in metropolitan Chicago use carve-out programs. "Except for mental health and chemical dependency we have not seen any other diseases carved out, but it's still of grave concern," says Sacks. "We have had bad experiences during the past eight years with behavioral health. I understand why they carved it out, because it was a high-cost area that no one was very successful at getting under control."

The specialist's role

Disease management is an effort, in part, to redefine the role of specialists, says Winkenwerder. "But we're not going to have a new world in managed care in which specialists manage the whole continuum of care for patients." Before joining Emory, Winkenwerder was a consultant with a young company called Oncology Partners that manages cancer patients through a provider network. "I think it's actually a good sign," he says, "that specialists are increasingly interested in managing the whole patient and the cost of care that they control."

Danny Mendelson of The Lewin Group agrees. Mendelson, who did a report for nephrologists on renal disease, says patients should be able to go directly to specialists. "The gatekeeper model that many HMOs have adopted isn't really the way to go for patients with chronic diseases," he says. "People with heart disease in a managed care plan often have to go through a primary care doctor before they go to their cardiologist. It makes more sense for that person's disease to be managed by a cardiologist.

"Primary care physicians will be a staple of managed care," he adds, "but when a disease management program is specializing in an illness it makes sense to use a specialist in that area."

Sacks has no qualms about primary care physicians and specialists working together for the benefit of better patient outcomes and reduced costs, but he's anxious about the trend to carve out certain diseases to specialty groups. "Once you carve things out you give doctors perverse incentives," says Sacks.

Nesse agrees. "In some cases the carve-outs of diseases lead to cost-shifting, rather than cost savings," he says. In some situations, Nesse supports using carve-out programs for such diseases as hemophilia and cystic fibrosis, which lend themselves to case management and have high-intensity subspecialty services, but he generally advocates an integrated provider approach.

Sacks offers back pain as a high-cost problem that causes lots of patients to miss work — therefore in one sense a natural for the extra clinical focus carve-outs imply. "But who gets paid? Do you pay the primary care doctor, the orthopedist, the neurologist, the neurosurgeon or the rheumatologist? And once you pick one of them, will everybody say they're not going to take care of these patients?"

"Some specialists see an inherent attraction to disease management to capture market share," says Harris. He says generalists and specialists should work on the same team, but he adds that primary care doctors don't always have to play a leading role. "If you look at the literature, a number of successful disease management programs don't use doctors at all."

Often, doctors can also use mid-level providers to ensure that the programs are implemented correctly. Sacks says, "Physicians who have incorporated mid-level providers into their practice settings have been more successful than those who have tried to do it on their own."

Sacks adds that when he was in clinical practice he realized that he needed to train and educate patients and "I will be the first to admit that I probably didn't do it very well." It was only at the end of his 13 years in practice that Sacks thought about telling asthmatics to use peak-flow meters, but he didn't have the nonphysician staff to help him. That's why he and so many others advocate a teamwork approach.

"We've only scratched the surface and we will only be limited by our creativity," he says.

Disease management's most promising targets

The biggest bang for disease management programs will come from managing those patients with conditions that are common, expensive and treatable. Figures below show how much is spent on the most commonly targeted diseases out of 1995's estimated $1 trillion national health care budget.

In billions

Asthma $4.7
Benign prostatic hyperplasia $4
Cancer $35
Cardiovascular disease $110
Diabetes $113
Mental illness $85
Peptic ulcer disease $3.7
Other conditions $644.6

SOURCE: THE LEWIN GROUP, FAIRFAX, VA.

The origin and mission of disease management

"The term 'disease management' as it is used today came out of the National Pharmaceutical Council," recalls Kenneth Cohen, vice president of managed care for that organization. "Then Pfizer was astute enough to work with The Boston Consulting Group, which did an authoritative paper on the topic two years ago. The BCG paper was so well received that disease management became a ubiquitous phrase. I think in the beginning we probably used it without realizing we were coining a term."

Drugmakers quickly embraced the concept as a new way to sell drugs to managed care organizations. They needed a way to get into the hearts and wallets of HMOs, recalls John Harris, M.D., former medical director of CaliforniaCare, who sat through many sales pitches from pharmaceutical manufacturers. "HMOs had an increasing amount of purchasing power and the drug companies wanted to avoid getting into a pure discounting price war." Since then, most drug companies have moved beyond programs limited to marketing products and are bundling programs with educational and preventive measures that providers will want to use.

At its most comprehensive — and theoretically its most effective — disease management takes in all the providers and facilities that would ordinarily deal with a patient: physician, pharmacist, nurse, hospital, lab, managed care organization and drug manufacturer. It relies on comprehensive, sophisticated data collection and analysis to track patients' progress and to determine what works best for most patients and how much it costs. "Disease management concepts are better suited to new integrated delivery models than to the traditional, fragmented health care delivery system," says Harris.

Paul Wynn
Associate Editor

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