Precept Employee Benefits Blog

View the rest of Dr. Coulter’s four-part series on disease management…

As we discussed in Part 1, the first challenge in getting good disease management results is to make sure that your vendor has identified your health plan beneficiaries who would be good candidates for disease management programs and assessed their needs, risks, and motivation (see Part 1).   The 300 diabetic members in your health plan, for example, are getting pharmacy and physician services, and you expect to see them identified by the disease management program.

So far, so good.  Sometime later, probably after the 1st Quarter program activity is reported, you wonder how many of those 300 diabetics are being served by the program.  The answer, clearly stated in the disease management report, is that 285 members, 95% of those identified, are “participants” in the program.  Sounds great, right?  But how come none of your coworkers who have diabetes are getting the coaching that the program promised when you signed up?

As a result of “opt-out” program designs, once someone is identified as having a disease like diabetes, they are mailed some program materials and told to call to “opt out” of the program.  Less than 5% will do so – if you didn’t want to participate, would you bother to call in response to an unsolicited letter?  The result is that 95% got a letter and some program materials, did not call in to refuse the program, and are now “participants.”

The problem is that mailing some program materials does not change health behaviors, does not teach diabetics better self-care, and does not provide oversight to make sure they are getting the best possible care.  If that were all it took, we could skip the coaching entirely:  nurses are expensive.  But the evidence shows that mail-only programs do not result in better behavior or understanding, do not improve care or outcomes, and do not result in lower costs.  As you look deeper into the reporting, you realize that only 10 or 20 of your diabetics are actually getting disease management.  Yes, as few as 5% of your diabetics, or even less with some vendors, will actually get the disease management you paid for.

What you were promised when you bought the disease management program, and what has been show to be effective in improving outcomes and reducing costs, is active coaching by nurses.  It is the therapeutic relationship between a nurse and a patient that works the magic in disease management programs, and this doesn’t happen with a booklet in the mail.

Bottom line: look at the number of your beneficiaries getting active coaching, not the number of program “participants,” to see whether you’re getting the disease management program you paid for.