Disease Management Megatrends: State-of-the-Industry 2008 and Beyond Delivering on promises... January 2008 Vince Kuraitis JD, MBA Better Health Technologies, LLC www.e-CareManagement.com blog (208) 395-1197
Despite Efforts to Date, the Chronic Care Challenge is Growing
Over the next 10 years, the global incidence of chronic disease is predicted to increase by 17% , further fueling the global burden of disease. Several factors account for this driving force:
The success of modern healthcare in transforming formerly lethal diseases, injuries, and conditions (e.g., HIV, spinal cord injuries, diabetes, tuberculosis, and multiple sclerosis) into chronic conditions that require continuous treatment;
Reductions in premature mortality and increasing longevity resulting in longer-lived chronic conditions and health-related dependencies; and
Increases in the behaviors (e.g., unhealthy diet, physical inactivity, and tobacco use) that significantly contribute to many prevalent chronic diseases.
Chronic disease is gaining increasing global attention....
The $30 Billion Potential DM Market is Barely Penetrated Source: Chris Selecky, President of DMAA and Chair, Lifemasters, 2005 Available Market based on Wachovia Capital Markets Formula Medicaid Market Opens with FL Healthplans and Self Funded Employers FEHBP Plans Start Adding DM CCIP Phase 1 CCIP Expansion
Medicare Health Support (MHS) appeared to be the favorite son demo to expand DM into Medicare
MHS has attracted worldwide attention
Legislation requires roll out if successful
Elements of MHS model
Focus on highest cost/risk population (frail elderly)
Disease management -- carve out to private companies & health plans ( vs. CCM)
Guaranteed 5% savings business model
Short term ROI
Randomized control trial
Results to-date: little evidence of success. See First “Official” Report on Medicare Health Support DM Pilot Finds Virtually No Evidence of Success , Disease Management and the Medicare Health Support (MHS) Project: “Houston, we have a problem.”
First, although the intervention and comparison groups are similar at randomization, our analyses reveal that an unexpected pattern in PBPM differences between intervention and comparison groups emerges between the time of randomization and the start of the MHS pilots.
Second, participating beneficiaries tend to be a healthier and less costly subset of the intervention group. Thus, high participation rates will likely be a factor in the ability of the MHSOs to impact their assigned intervention populations . And,
Third, fees paid to date far exceed any savings produced . The negotiated MHSO monthly fees are a much higher percentage of the comparison groups’ PBPMs than the percentage savings on payments through the first 6-month pilot period. Fees negotiated by the MHSOs with CMS have not been covered by reductions in Medicare expenditures, let alone an additional 5% savings in Medicare payments. Without a substantial reduction in each MHSO’s monthly fee, budget neutrality after the first year is questionable .
Source: RTI International Report to Congress: Evaluation of Phase I of Medicare Health Support (Formerly Voluntary Chronic Care Improvement) Pilot Program Under Traditional Fee-for-Service Medicare , June 2007
Improvements in quality of care don’t guarantee better patient outcomes in short run
CMS’ Take on Medicare DM Demos Source: Linda Magno, CMS, presenting at the Patient Centered Primary Care Collaborative Summit , November 2007
Many Other CMS Demo/Pilot Projects Involve Patients With Chronic Diseases
Medicare is undertaking a wide range of demonstration/pilot projects
Many directly involve patients with chronic conditions
Physician Group Practice (PGP)
Care Management for High Cost Beneficiaries (CMHCB)
Special Needs Plans (SNP)
Medicare Medical Home demonstration (discussed later)
What are some of Medicare’s other options toward an optimal chronic care management program?
From: a guaranteed 5% savings business model
To: considering many alternative payment mechanisms: capitation, shared savings, pay-for-performance, and/or fee-for-service DM.
From: focusing on short-term ROI
To: focusing on medium-long term ROI, quality improvement & compression of morbidity
From: DM carve outs to private companies & health plans
To: exploring options to re-integrate care providers into care management processes, e.g., the Chronic Care Model, the Medical Home model or a managed care model (e.g. utilization review, case management, pre-certification, etc.).
From: focusing on high-risk, chronic, co-morbid patients
To: including programs to address mainstream Medicare patients with prevention and population health approaches
From: rigid implementation of inflexible program structures
To: Rapid Learning Models. Open up the data, while protecting for personal identification, to all “qualified” people to learn what can be learned in a timely fashion. The process should be transparent and open and available to the taxpayers who have funded these demonstrations.
From: is MHS working as originally designed?
To: what’s the optimal chronic care management program, financing structure, and evaluation model for Medicare?
PROVIDERS: Care providers have woken up to DM opportunities and threats; they are promoting the Chronic Care Model and the medical home.
Challenges: no reimbursement, academic/research focus
23 Aspects of the Chronic Care Model Delivery System Design Decision Support Clinical Information Systems Self-Management Support Health System Organization Links to Community Resources Source: Pearson, M. et. al. Chronic Care Model Implementation Emphases , Rand Health Presentation to Academy Health Meeting, 2004 Leadership support Provider participation Coherent system QI Guidelines Provider education Expert support Registry Info for care man. Performance data Care man. roles Practice team Care coordination Proactive follow-up Planned visit Visit system changes Patient education Patient activation Self-man assessment Self-man resources Collaboration on decisions Guidelines to patients For patients For community
Personal communications devices -- PDAs, cell phones, etc.
Broadband -- cable, DSL, satellite
Digital cameras, video
Wireless -- 802.11, Bluetooth, RFID, etc.
Electronic Health Records (EHRs)
Personal Health Records (PHRs)
Remote patient monitoring
Self care support
Physician/patient secure messaging
Decision support systems
Computerized Physician Order Entry
Quality evaluation web sites
Patient reminder systems
Focal Points for Convergence Home Networks, Smart Phones, EHRs
PHR/ EHR eHEALTH Smart Phone Home Network
Role of IT in Disease Management Patient Facing DM Provider Facing Patient-provider communication tools (IVR, email) Monitor Engage Intervene Educate, Coordinate, Treat Identify, Validate, Stratify, Enroll Call center Personal Health Record Predictive modeling Remote monitoring (biometric, tele-monitoring) Personal assessment tools (HRA) Educational tools (websites, audio library) Electronic Medical Record Decision support tools (CDSS) Outcomes, Feedback, Follow-up Clinical integration tools Disease registry
C) Forrester says “$34 B Market for Healthcare Unbound Technologies by 2015” 80% is Chronic Care Total Acute Chronic ADL/elder $0.35 $US (billions) $0.37 $0.47 $0.59 $0.73 $0.98 $1.2 $1.6 $2.0 $2.4 $3.0 $3.7 $0.10 $0.13 $0.22 $0.38 $0.65 $1.2 $3.8 $12.1 $23.1 $26.3 $25.7 $26.7 $0.00 $0.00 $0.00 $0.00 $0.01 $0.02 $0.65 $2.0 $3.6 $3.5 $3.0 $3.2 $0.45 $0.50 $0.69 $0.97 $1.4 $2.1 $5.7 $15.7 $28.7 $32.3 $31.7 $33.6 (Numbers have been rounded)
More than 50 years of research on health behavior change has not provided us with easy answers in understanding patient nonadherence.
Despite the renewed interest in adherence research, we have a long road ahead in translating behavior change principles into practical application.
Actionable messages are critical to success.
When physicians and other health care professionals use their referent power they can be influential in patient adherence....higher patient adherence is associated with physicians who create warm personal relationships with their patients, and work with them to address adherence and lifestyle issues.
Expanding referent power beyond physicians to patient-affiliated reference groups may be challenging to DM, but it may increase the influence of adherence messages exponentially.
Source: Turpin, R. et. al. “Patient Adherence: Present State and Future Directions” Disease Management , December 2007
CLINICAL AND ECONOMIC ROI: Round one is over, DM wins; Round 2 has just begun.
The DM/ROI Debate Of the Past 10 Years Has Not Always Been Framed Constructively
“DM has ROI”
“No it doesn’t”
“Yes it does”
“No it doesn’t”
“Jane, you ignorant slut”
Reframing the DM/ROI Debate: 2 Seemingly Contradictory Statements
#1: Whether DM provides ROI has become irrelevant
#2: The DM/ROI debate will continue to be scientifically evaluated for the next decade
#1: The DM/ROI Debate Has Become Irrelevant DM Has Gone Mainstream
#2: The DM/ROI Debate Will Continue To Be Scientifically Evaluated For The Next Decade
#1 = DM today
#2 = Continuing DM ROI and outcome measurement for the future
No evidence Preponderance of Evidence Beyond A Reasonable Doubt Clear and Convincing Evidence Absolute Certainty 0 100 Level of Proof
Source: With attribution to Gordon Norman, MD, MBA, Chief Medical Officer of Alere
Will We Ever “Get Along” and Measure Outcomes and ROI Consistently?
In 2006, DMAA released the first volume of its long-awaited Outcomes Guidelines Report , which described industry consensus approaches to measuring financial outcomes in disease management.
In 2007, a follow-up document, the Outcomes Guidelines Report Volume II, added clinical measures.
In 2008, a third volume of the report is planned for publication.
These are significant steps...but don’t expect the debate AND controversy about ROI to end soon.
From: Acute and episodic care delivered in hospitals and doctors’ offices
To: Chronic disease and condition management delivered in homes, workplaces, and communities
BHT provides consulting, business development, and speaking services to assist companies in: 1) Understanding the shift 2) Positioning – what’s the right strategy, tactics, and business model? 3) Integrating your offering into the value chain – what are the right partnerships?