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Getting Serious About Disease Management
 Despite the uncertainty surrounding the final result of
health care legislation, it's comforting to know some
management challenges transcend the vagaries of
politics and regulatory agencies. One of those
constants is optimization of administrative spend.
Traditionally, it is an area of management focus
applicable to all functions including medical
management, of which disease management is a
part. It is also an area of focus that may be elevated to
critical importance if Section 102 of House Bill HR
3962 makes its way through committee and into law.
This is the section that mandates, beginning January
1, 2010, at least 85% of premium dollars for
large-group, small-group, and individual policies must
be
spent on medical treatment, leaving (at most) 15% for
marketing, sales, administrative expense, other
expenses and, for commercial carriers, profit. In that
environment, creating and maintaining an effective
disease management capability presents special
challenges, but this would also present unique
opportunities for administrative savings, cost-of-care
benefits for self-insured groups, and marketplace
differentiation.
The importance of disease management as a
means to improve members' quality of life and to
help
control medical costs should be apparent to even a
casual observer. According to an Archives of
Internal Medicine study in 2004, 57 million
Americans suffered from one or more of the "Big
Five"
chronic conditions–diabetes, asthma,
congestive
heart failure (CHF), coronary artery disease, and
chronic obstructive pulmonary disease. That number
is expected to increase to 81 million by 2020.
Seventy-two percent of all physician visits and 88% of
all
prescriptions filled are for patients with one or more of
these conditions, which is 75% of all medical
spending in the United States. Yet, despite the
enormity of the problem, the verdict on the
effectiveness of disease management programs is
decidedly mixed and falls into three categories:
- At one end of the spectrum: Individual plan
studies showing meaningful cost of care savings for
targeted conditions.
- At the other end: A recent Congressional Budget
Office study stated there is insufficient data from large,
long-term studies to make any broad statements
about disease management programs' effectiveness
in reducing cost of care.
- And in the middle: A 2005 Society of
Actuaries study showed savings for some
condition programs but no savings for others. For
example, an $11-$145 PMPM savings for diabetes
programs; $150-$450 PMPM savings for CHF
programs; but no savings for asthma
programs.
The unmistakable message from all of this is that
health plans are presented with a growing, complex
problem that cannot be solved with broad brush
strokes. Although daunting, it's a problem we believe
can be effectively addressed, accomplishing the goals
of clinical staff optimization, cost-of-care reductions,
and market differentiation.
Effective disease management begins with two
guiding principles: targeted engagement and member
behavior modification. Without them, program benefit
expectations will simply not be met. These principles
have eight key tactical considerations which, in
aggregate, produce meaningful, qualitative, and
quantitative results.
- Integrity of member contact
information—accurate telephone numbers and
e-mail and postal addresses.
- Effective population risk scoring by age, gender,
condition, co-morbidity, and location (by zip code).
- Engagement outreach supported by customized
contact procedures for high-risk/high-potential
members. Many programs fail because all members
are treated equally from a procedural perspective,
often resulting in engagement of a preponderance of
lower-potential members.
- Member relationship building using a
declining-scale intervention frequency and contact
duration
model. Similar to personal relationship building,
contact with members should be frequent at the
beginning with comparatively more time invested
during each contact, then becoming less frequent and
less time-consuming as interim goals are met and
trust is developed. Too often, contact protocols call for
semi-monthly or monthly contact with members which
is an ineffective approach to creating an effective
relationship between the plan's clinician and the
member.
- Optimized post-engagement member contact
success ratios enabled by system-generated
reminder e-mails and/or automated reminder calls to
member-directed contact telephone numbers.
- Treatment protocols and associated quantitative
and qualitative improvement goals that correspond to
the declining-scale intervention process noted in #4.
Initial goals should be numerous, incremental toward
the ultimate health goal, and easily attainable.
Achievement of goals established later in the protocol
period should require comparatively more effort on the
part of the member.
- Quality-of-life and cost-of-care results reporting
compared to initial member surveys and similar,
unmanaged cohort claim costs.
- Manage caseloads by consistently closing cases
at the end of protocol periods in which optimal health
goals are met or for those members who are in
consistent non-compliance with treatment plans.
- Although not an easy task, thoughtful
implementation of these considerations should help
drive success; something that has eluded the vast
majority of the industry.
The Nolan Company wishes you good fortune in
2010. As needs arise, we would be pleased to speak
with you about your medical management strategies
for the new year.
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