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Getting a handle on chronic disease


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Getting a handle on chronic disease

  1. 1. Perspective Ramez Shehadi Ali Hashemi Walid Tohme Jad BitarGetting a Handle onChronic DiseaseHealth ManagementServices in the GCCRegion
  2. 2. Contact InformationBeirutRamez ShehadiPartner+961-1-985-655ramez.shehadi@booz.comWalid TohmePrincipal+961-1-985-655walid.tohme@booz.comJad BitarSenior Associate+961-1-985-655jad.bitar@booz.comDubaiAli Booz & Company
  3. 3. EXECUTIVE The growing prevalence of chronic diseases in Gulf Cooperation Council (GCC)1 nations has socioeconomicSUMMARY implications that are quickly adding up. Chronic diseases generate higher healthcare costs, which are borne by govern- ments, insurers, and patients. They also lower productivity among workers, clog healthcare service channels, and bring about declines in a population’s health status. As GCC nations continue to invest in their healthcare systems, the region’s leaders should take their cue from certain developed nations in adopting health management services (HMS) to help address the specter of a chronic disease epidemic. HMS programs address critical gaps practices—including effective use of in the care of chronically ill patients incentives, physician involvement, and by helping them understand the personalization—can help HMS pro- implications of their disease and grams achieve their goals. But before underlying lifestyle factors, amend GCC governments and healthcare their harmful behavior, adhere to organizations can implement HMS treatment regimens, and navigate the programs, they will need to answer healthcare system. HMS programs strategic questions about the segments have been proven to be successful at of society that should be targeted, the improving individuals’ health and programs that will be most relevant, generating significant savings for the incentives that would encourage healthcare payors when all stakehold- involvement, the funding mechanism ers—patients, physicians, hospitals, that will support HMS, the objec- insurers, and government—buy into tives of the program, and the roles of their development. A number of best public and private entities.Booz & Company 1
  4. 4. KEY HIGHLIGHTS• HMS programs are a key tool in the effort to halt the rise of chronic diseases in GCC countries and keep healthcare costs in check.• Numerous studies have demonstrated the benefits of HMS on individuals’ health and on overall healthcare cost management.• HMS programs blend wellness services that provide healthy individuals with information and encouragement to better manage their health risks with disease management that increases chronically ill patients’ compliance THE RUNAWAY hidden costs on society, such as lower worker productivity. Recent research with prescribed treatments. COSTS OF shows that on-the-job productivity• Effective HMS programs are CHRONIC losses account for up to 60 percent2 of the total healthcare costs associated characterized by three common themes: incentives to ensure DISEASES with chronic diseases. patient participation, strategies to To counter these trends, care provid- involve physicians as key program ers in North America are increasingly facilitators, and communications turning to health management services and incentives that are tailored to (HMS). These services primarily work individual preferences. Around the world, unhealthy lifestyles in two ways: They help mitigate the and aging populations are leading to a spread of chronic diseases by estab- higher prevalence of chronic disease, lishing wellness programs and other thus driving up healthcare costs and preventive strategies, and they reduce keeping economies from perform- the costs of treating chronic diseases ing at their true potential. Chronic once they are diagnosed through diseases strain healthcare providers ongoing monitoring and frequent and the overall healthcare system interaction with patients. with patients’ frequent and costly trips to the emergency room (ER) HMS will be a critical element of and longer average stays. Long and GCC countries’ overall healthcare resource-intensive treatment periods strategies in the future, as chronic make patients with chronic disease diseases exact a toll in terms of costs, heavy users of healthcare services, strain on providers, and healthcare leading them to consume a dispropor- status: In the coming years, chronic tionate amount of the total available diseases are expected to account for services. This has a severe impact on a significant portion of healthcare the distribution of those services and expenses. As governments, healthcare clogs providers’ ER and other delivery organizations, and private insurers in channels. the region look to develop a compre- hensive health management strategy Chronic diseases not only negatively that addresses this mounting problem, affect a population’s general health HMS programs are a key tool. status, but they also levy serious2 Booz & Company
  5. 5. A PRESSING The rapid economic expansion of the GCC region has brought its member an increasing prevalence of chronic diseases among their citizenry.PROBLEM FOR nations the benefits of advancedGCC NATIONS “developed” countries—higher stan- dards of living, lower unemployment, In the typical GCC country today, chronic diseases are a leading cause and increased purchasing power. of mortality; in 2007, the region was But along with such advantages also home to four of the top five nations come new and pressing challenges, in the world for diabetes cases among particularly in the realm of health- adults (see Exhibit 1). Based on data care. In recent years, GCC nations available from several GCC geog- effectively combated typical “third raphies, chronic diseases currently world” health challenges such as account for approximately 35 percent tuberculosis and malaria. However, or more of the deaths in those due to the rapid growth and develop- regions—fast approaching levels in ment of the region and the resultant developed countries such as the U.S., change in lifestyles, GCC leaders where chronic diseases account for an are now turning their attention to estimated 70 percent of mortalities. Exhibit 1 Prevalence of Chronic Diseases in the GCC Region LEADING CAUSES OF DEATH IN ABU DHABI 2007 23% Accidents/Injury 32% Cardiovascular Cancer Diabetes 18% Congenital 6% Other 7% 14% PERCENTAGE OF ADULT POPULATION WITH DIABETES BY RANKING 2007 30.7% 19.5% 16.7% 15.2% 14.4% 13.1% 11.0% 7.8% Nauru UAE Saudi Bahrain Kuwait Oman Egypt USA Arabia Source: HAAD statistics; World Health OrganizationBooz & Company 3
  6. 6. Lifestyle factors in the GCC region Because many of these factors are not ditures than governments in otherhave contributed mightily to this addressed before they mature into parts of the world. Public spendingscourge, setting the stage for the chronic diseases, GCC governments on healthcare averaged 74 percentcreation of a chronic disease epi- are being forced to dedicate more of in GCC countries in 2006, nearly 20demic. Increasing affluence in GCC their budgets to treat a growing wave percentage points higher than thecountries has caused a once highly of patients. In the UAE, where one in global average of 57 percent4 (seeactive population to become largely every five adults is afflicted with dia- Exhibit 2). But the issue also loomssedentary, resulting in reduced levels betes, treatment of that illness alone large for the private insurance compa-of physical activity, increased smoking takes up approximately 40 percent of nies that are entering GCC markets,rates, and other unhealthy lifestyle the nation’s overall healthcare expen- which need to keep their costs downchanges. These changes are triggering ditures.3 The burden posed by chronic to remain competitive.heightened obesity rates and inci- diseases weighs more heavily on GCCdences of hypertension, key factors governments because they shoulderthat contribute to chronic disease. a greater share of healthcare expen-Exhibit 2GCC Governments Contribute Significantly More to Healthcare Costs Than the Global AverageSHARE OF PUBLIC EXPENDITURE IN HEALTHCARE2006 90%Public Expenditure as a % of Total Healthcare Expenditure 80% GCC Average = 74% 70% Top 30 HDI* Average = 71% 60% World Average* = 57% 50% 40% 30% United Japan Sweden France Germany Canada Australia Switzerland Republic United China Oman Kuwait Saudi Qatar United Bahrain Kingdom of Korea States of Arabia Arab America Emirates*HDI = Human Development Index; World Average is based on 177 countries; Top 30 excludes Hong Kong, for which figures were not available.Source: WHO Statistical Information System, 2006 data4 Booz & Company
  7. 7. ADDRESSING Needless to say, the rising socioeco- nomic costs of chronic diseases have Typically, chronically ill patients need assistance in four major elements ofGAPS IN PATIENT caught the attention of GCC govern- their disease management: under-CARE ments. Some have set up government bodies and programs to develop standing the implications of their dis- ease, such as treatment options, risk preventative healthcare strategies and factors, and potential complications; address the low level of health aware- navigating the healthcare system ness in the region. In many cases and communicating with the various involving chronic diseases, consumers care providers, especially for patients have little knowledge about preven- with multiple chronic diseases who tion and management of their condi- must make multiple visits; gathering tions. For instance, a study about information about the various actions osteoporosis among educated women they need to undertake, including in the UAE found that 44 percent self-care, dietary changes, and exer- of women with at least a secondary cise; and complying with their care school education had minimal or zero regimen, such as planning multiple knowledge of the disease.5 provider visits and taking prescribed medicines.6 To date, however, such government programs have not been able to Currently, though, such needs are fully address the escalating needs of filled only during formal physician the GCC region’s large and grow- visits or informally by other sources ing population of chronic disease such as family and friends. These sufferers. Post-diagnosis, chronic interactions only partially address a disease patients have a broad array of chronically ill patient’s continuous clinical and non-clinical needs associ- need for care advice, monitoring, and ated with managing their condition. compliance. As such, critical gaps in Diabetics, for example, need to care provision exist before, between, continually manage their disease, on and after provider visits, particularly top of identifying and changing the when it comes to identifying high-risk lifestyle factors that caused it. Their behavior, adhering to a treatment responsibilities include measuring regimen, patient monitoring, and blood glucose levels, taking insulin other elements of care coordination. shots, and getting regular screenings and tests.Booz & Company 5
  8. 8. FACTS AND FIGURES THE CASE FOR• Obesity: GCC nations are home to some of the highest obesity rates in the world. Thirty percent or more of the adult populations in Saudi Arabia, the HMS UAE, Kuwait, and Bahrain have a body mass index (BMI) of 30 or more, the clinical definition of obese. In Abu Dhabi, the average BMI is 29 among adults.i• Smoking: GCC countries have a relatively moderate number of smokers—36 To close these gaps and improve percent versus a global average of 33 percent. But on a per capita basis, the overall care of chronically their annual intake of cigarettes is much higher, fueled by higher consumption ill patients, healthcare leaders in among young males. For example, the average Kuwaiti smoker consumes some developed economies are more than 2,500 cigarettes a year, compared with a worldwide average of employing HMS, which bundle a 900. prescribed set of healthcare services into condition-specific programs• Physical Inactivity: At least 40 percent of the GCC population fails to achieve that are based on scientific evidence the minimum daily recommendation of 30 minutes of moderate-intensity and data analysis. The healthcare physical activity. This rate is more than double the global estimate of 17 services address the patients’ needs percent.ii identified above: risk identification,• Hypertension: Modernization has been directly linked to higher stress levels awareness and education, adherence in GCC nations. Roughly 34 percentiii of the adult population in Abu Dhabi to treatment regimen, monitoring has high blood pressure, compared with just 18 percent in the U.S. Statistics health indicators, and care also reveal a high correlation between hypertension and the occurrence of coordination. The HMS program diabetes. encourages individual members to improve their health by creating a support system that helps them manage their condition, increasing their awareness, providing critical guidance, and employing incentives to encourage healthy behavior. HMS also strengthen relationships between hospitals and their patients and physicians, by creating a continuous, longitudinal view of patient care that competitors cannot match.6 Booz & Company
  9. 9. As an example, diabetics enrolled in Coaching and intervention-related such savings are often difficult toan HMS program designed to help services are at the core of HMS quantify, numerous studies havemanage their condition can expect the programs and they are typically demonstrated the benefits of HMSfollowing services: conducted by a call center staffed on individuals’ health, as well as on by nurses. The call centers contact overall healthcare costs. For instance,• Comprehensive diabetes plan patients to provide them with vari- a study published in Health Affairs including diet, medication, exercise, ous services based on the program in 2004 showed an 8.1 percent drop and screening in which the patient is enrolled in hospitalization costs of diabetes (e.g., information on care regimen, patients after they were enrolled in• Diabetes articles and the latest reminders for screening, coordinat- an HMS program to help manage research on diabetes ing physician visits). Through these their treatment.7 A separate finding coaching and intervention services, published in 2005 in the European• Coordination with provider HMS provide consumers with the Journal of Public Health found that information and guidance required HMS smoking cessation programs• Remote consultation and setting of while coordinating care in order to resulted in a 15 percent to 35 percent appointments help consumers manage their health quit rate, saving employers (here and directly address the gaps in care collectively referred to as payors) an• Diabetic community tools provision. average of US$11,880 per smoker over their lifetimes.8• Glycemic index counter and low By supporting individuals in main- glycemic food guide taining their health and helping chronic patients with their condi-• Medication and screening test tions, HMS programs have a direct alerts impact on healthcare costs. Although By supporting individuals in maintaining their health and helping chronic patients with their conditions, HMS programs have a direct impact on healthcare costs.Booz & Company 7
  10. 10. Such success stories have led health HEALTH MANAGEMENT GOES ONLINEinsurance companies and payors to HMS providers are increasingly leveraging technology to conduct data analytics,increasingly adopt these services as integrate remote monitoring devices, and leverage alternative access channels.a way of controlling their soaring Still, it wasn’t until recently that HMS began migrating to Internet-basedhealthcare costs. The HMS industry platforms. Traditionally, health management programs were delivered solelyhas been growing significantly in through a nurse or a coach—an expensive medium for parlaying services. In theearly adopter markets such as the interest of reducing costs, providers have begun effectively incorporating Web-U.S., where it has enjoyed a com- based programs in conjunction with coaches and nurse-staffed call centers.pound annual growth rate of more Another advantage to online HMS is it provides more leeway to personalizethan 25 percent over the past decade program elements, which evidence shows increases patients’ participation inand now enjoys a penetration rate and compliance with HMS programs.of 5 percent to 10 percent of totalinsured lives.9 In recent years, pilot Citing these advantages, leading HMS providers are making acquisitionsHMS programs have begun to crop and other key investments to incorporate Internet-based models as a keyup in Latin America, Europe, and vehicle for delivering HMS programs. In fact, certain leading-edge providersAsia. Payors especially have found have introduced programs that are delivered exclusively over the Internet.these programs to be beneficial, due Leading HMS companies, including Healthways Inc. and Matria Healthcare,to their positive impact on employee have made notable forays into online program delivery. Healthways has madeproductivity and satisfaction. significant, targeted investments in this area, mainly focused on building anAdditionally, HMS programs are one internal technology team that could help it deliver an online platform for itsof the few options available to payors programs, while Matria, now part of Alere Medical, acquired online HMS providerthat believe that prevention needs to Conversely, leading healthcare portals such as WebMD andbe a key element of their healthcare Revolution Health have purchased companies to add HMS programs to theircost containment strategy. A recent already popular Web services.evolution in the HMS delivery modelhas been the integration of Internet-based platforms, while face-to-facecoaching continues to be used todeliver interventions (see “HealthManagement Goes Online”). HMS programs are one of the few options available to payors that believe that prevention needs to be a key element of their cost-containment strategy.8 Booz & Company
  11. 11. KEY screenings and immunizations (e.g., flu shots), and share information to Both types of HMS program are typically designed around four majorCOMPONENTS OF foster self-care practices. Follow-up components:HMS PROGRAMS support is provided by on-site, telephone-based, or online coaching • Adoption focuses on understand- assistance through condition-specific ing members’ or employees’ needs, programs such as weight manage- evaluating patients’ risk profiles ment, smoking cessation, and stress through health-risk appraisals, management. selecting the appropriate programHMS programs are broadly classified and pricing strategy, and encourag-as either wellness programs or disease Disease-management programs offer a ing adoption through marketingmanagement programs. Whereas prospective, disease-specific approach efforts and enrollment incentives.the latter deals with patients already to coordinating the care of high-afflicted with chronic diseases, the cost and high-risk populations with • Program delivery centers on coreformer aims to reduce risk fac- chronic conditions, including dia- intervention elements that aretors that cause the onset of chronic betes, asthma, and congestive heart designed to help the consumerdiseases in the first place through the failure. They typically involve a coor- manage his or her condition andpursuit of mental and physical well- dinated set of healthcare interven- reduce risk factors through a per-being. tions and communications designed sonalized delivery strategy. to support the patient–physicianTypical wellness programs provide relationship by ensuring the patient’s • Monitoring sets clear performancehealthy individuals with information, compliance with the prescribed metrics, measures against them,support, guidance, and encourage- care plan. These programs focus and verifies desired outcomes.ment to better manage their lifestyle- on keeping conditions from beingrelated health risks. First, health-risk exacerbated, through co-morbidities • Improvement involves modifyingassessments help assign consumers to or other complications, by using the program elements to enhancevarious risk groups. Then providers evidence-based practice guidelines the effectiveness of the preventive measures such as and strategies to empower patients.Booz & Company 9
  12. 12. PUTTING HMS To be sure, health management is not an exact science, given that the awareness of health issues in GCC countries, there is greater relianceINTO PRACTICE success of these programs depends on physicians by patients, making to a large extent on their ability to physician involvement all the more change behavior. The HMS industry critical. HMS programs in the region is constantly innovating to develop will need to engage relevant physi- new techniques to improve programs’ cian groups to obtain their buy-in ability to ensure compliance, reduce and ensure their participation and risk factors, and carry out preventive involvement. screenings and thus deliver on their promised benefits. There are three key Personalization: Tailoring com- ingredients in successfully deployed munications and incentives to the HMS programs, all of which can be individual’s tastes and preferences is leveraged in GCC markets: a new and evolving trend credited with increasing patient compliance Incentives: Well-designed HMS with HMS programs. Participants programs provide consumers with a receive personalized letters, educa- variety of incentives to ensure partici- tional brochures, and booklets to pation, such as reduced premiums, increase awareness. Incentives and cash incentives, and redeemable other aspects of the plan’s design are reward points akin to points given customized to adjust to the individual by various reward programs. HMS participant’s ability to change. HMS programs are also using negative providers are building large databases incentives such as higher premiums of consumer information to document or co-pays for non-participants. the success of interventions, incen- Increasingly, programs are adopt- tives, and communications, and to ing a combination of both—negative leverage these large data warehouses incentives to ensure enrollment and to personalize their interactions with positive incentives to effect behavioral other members. change. The ways in which these building Physician Involvement: Coordinating blocks are used will be determined program interventions and other by healthcare payors’ overall HMS elements with the patient’s physi- strategy, which will require analysis, cian is another critical facilitator in judgment, detailed design, and pilot- assuring program efficacy. In a case ing of alternative concepts, as well where drug adherence is identified as allocation of significant resources as a problem, for instance, involving for implementation. Payors will also the physician isn’t just about relat- likely require the involvement of lead- ing critical information; it creates an ing disease management and wellness opportunity for the physician to inter- companies from mature HMS mar- vene and reinforce the importance of kets—primarily the U.S.—to ensure sticking to the drug regimen. Given that the plan imperatives highlighted the low level of health literacy and above are incorporated.10 Booz & Company
  13. 13. CONCLUSION To help jump-start the process and lay a sound foundation for successful • What would be the financial and health status objectives of HMS implementation, GCC governments programs? Should GCC govern- and healthcare organizations must ments support these programs if assess their current overall healthcare the financial return on investment strategy to address a number of stra- is not clear but there is a positive tegic questions: impact on the health status of the population? What will be the role • How should HMS programs be of healthcare providers and health integrated into their current health- insurance companies? care strategic framework? • Through which entity will the • Which segments of the population programs be offered? Will it be a will be targeted? How will the pro- public–private partnership between gram design be modified to address a GCC government and an interna- the cultural characteristics of the tional disease management/wellness population? company, or will it be an entirely private undertaking? • Which HMS programs would be most relevant for GCC • What policy initiatives will be populations? required to support HMS rollout? • What incentives will be required to • How will GCC governments ensure ensure significant program adop- that other healthcare stakeholders, tion among targeted segments? primarily providers, support the rollout of the HMS programs? • How will health management ser- vices be funded? How will the costs • What will be the role of e-health in (and risks) be distributed among delivering HMS to the population? the various stakeholders?Booz & Company 11
  14. 14. • How will the execution of HMS productivity, and immense strain on ing significant investments in their programs be managed across the healthcare system. healthcare systems. Indeed, rapid various governmental authorities? implementation of such programs is What are the critical factors for the Well-crafted HMS programs are a within grasp for smaller markets in successful execution and rollout of valuable tool that can help GCC the region. HMS programs? nations stem the rising tide of chronic diseases by helping to identify As GCC nations prime for a robustChronic disease management is unhealthy and risky behaviors, raise economic recovery, their leaders willan issue that GCC nations can ill awareness of underlying lifestyle fac- need to put a premium on “smartafford to ignore. Countries that fail tors, improve adherence to treatment growth” strategies. When it comesto address this pressing concern run regimens, and strengthen the bonds to managing the population’s mosta real risk of being engulfed in a between patients and physicians. serious and costly illnesses, there ischronic disease epidemic, resulting Now is an opportune time for GCC no smarter healthcare strategy thanin reduced health status, crippling nations to adopt HMS programs as costs, lower workforce most GCC nations are undertak-12 Booz & Company
  15. 15. Endnotes1 The Gulf Cooperation Council consists of Bahrain, Kuwait, 7 Victor G. Villagra and Tamim Ahmed, “Effectiveness of a DiseaseOman, Qatar, Saudi Arabia, and the United Arab Emirates. Management Program for Patients with Diabetes,” Health Affairs, vol. 23, no. 4, 2004, 255–266.2 WHO Mortality Fact Sheet for Saudi Arabia (2006) and QatarMinistry of Health statistics. 8 Susanne R. Rasmussen, Eva Prescott, Thorkild I. A. Sørensen, and Jes Søgaard, “The Total Lifetime Health Cost Savings of3 “Treatment of Diabetes a Big Drain on National Healthcare Bud- Smoking Cessation to Society,” European Journal of Publicget,” Gulf News, November 11, 2007. Health, vol. 15, no. 6, December 2005.4 WHO Statistical Information System, 2006 data. 9 Booz & Company estimates.5 Haider M. Al Attia, Amal A. Abu Merhi, and Maha M. Al Farhan, i Health Authority–Abu Dhabi (HAAD) statistics.“How Much Do the Arab Females Know about Osteoporosis? TheScope and the Sources of Knowledge,” Clinical Rheumatology, World Health Organization and Oxford Health Alliance; the rates iivol. 27, no. 9, September 2008, 1167–1170. for physical inactivity in UAE were for the top and bottom quintiles of income class.6 A presumably simple element of the compliance regimen,adherence to prescribed drug regimen, suffers from a large iii HAAD statistics.noncompliance rate.About the AuthorsRamez Shehadi is a partner Walid Tohme is a principal withwith Booz & Company in Booz & Company in Beirut andBeirut. He leads the informa- a leader in the information tech-tion technology practice in the nology practice with a focus onMiddle East. He specializes in healthcare. He specializes ine-government, e-business, and the management and strategictechnology-enabled transfor- use of technology to enable themation, helping both private transformation of healthcarecorporations and govern- organizations, services, andment organizations leverage, achieve operationalefficiencies, and improve Jad Bitar is a senior associategovernance. with Booz & Company in Beirut and a leader in the informa-Ali Hashemi is a principal with tion technology practice withBooz & Company in Dubai a focus on healthcare. Heand a leader in the healthcare specializes in healthcare andpractice in the Middle East. business technology, par-He specializes in business ticularly strategy, organization,strategy for players throughout operations, and innovation.the healthcare value chain, aswell as advising governmententities on defining their overallhealthcare agendas.Booz & Company 13
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