View the rest of Dr. Coulter’s four-part series on disease management…
Disease management programs can work wonders to improve the health status of individuals with diabetes, heart disease, and other medical conditions, and to lower the employer’s cost for medical care. Basically, whatever the diagnosis, the more you know and the better you care for yourself, the less expensive care is needed and the better the outcomes. This is especially true for avoiding ER visits and hospitalizations.
But all disease management programs are not alike, and one recent problem has been that the wrong patients get identified. Basically, health plans and disease management companies take medical claims and pharmacy data and try to figure out who has a medical diagnosis like diabetes. Once they are identified, the plan calls the individual to confirm that they really have diabetes, and then “stratifies” them, basically figuring out who needs more help.
To save money, though, some disease management vendors don’t bother calling everyone they have identified, they just “stratify” based on how much medical care they have received. The problem? Two – claims are often coded by physicians to maximize reimbursement, not necessarily to provide an accurate diagnosis. So as many as 10%, even 20%, of those identified as having a medical diagnosis, may not actually have it.
Even worse, if you don’t call, you have no idea what the patient’s history is, or how much they understand about their illness. It is impossible to tell who needs help the most, without knowing this information.
Bottom line: check if your disease management company calls everyone they identify with a diagnosis to give the best care, or is simply cutting corners.
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