Disease management has great promise, but it has been hyped and oversold. Too few programs today offer real substance, and the market is poised to turn hostile as this comes to light. Remember managed care in the 1990’s?
What happened? Disease management can be a real help to people with chronic illness, and it can save claim dollars for employers and other payers. That promise created a booming market for disease management, and a gold rush ensued as new entrants flooded the market and eroded the value of the service. Suddenly every health plan offered a disease management program, and many did not bother building the solid nursing foundation needed to deliver real results.
The heart of disease management is a therapeutic relationship between a nurse and a patient. That’s how you educate, change behaviors, assure quality care and create better outcomes. It helps if you can enlist the patient’s physician as well. Boxes full of literature, glitzy marketing campaigns and grandiose claims don’t do the difficult jobs of establishing that relationship, supporting patient education and self-care, and delivering better results.
Nurses are expensive. If you are a disease management company, you can under price your competition by having fewer patients in nurse coaching. And then don’t bother reporting that to the client – read a disease management activity report today and try to figure out how many health plan beneficiaries are actually getting nurse coaching. It’s the critical metric, but most disease management vendors don’t report it to their clients.
What’s the right number of a health plan’s diabetics that should be in nurse coaching? 50%? 25%? We can debate that, but I will guarantee you it’s not less than 2%, which is the result for some disease management programs today. There is no possibility that touching so few beneficiaries will result in a meaningful impact or real program savings. Unfortunately, disease management vendor estimates of savings and ROI are so mired in statistical problems, including selection bias and regression to the mean, that they cannot be relied on as a meaningful measure of the program impact. The industry missed a chance to standardize measurements of results to report valid metrics and allow meaningful comparison across vendors. This would have created a fair marketplace, assured accountability, and rewarded top performing organizations. Accountability and transparency could have headed off the problem we are approaching when nobody believes disease management savings and ROI reports.
We know we have a problem as disease management vendors withdraw from the Medicare demonstration project and reports appear more frequently that question the value of disease management. There’s a chance that this is simply part of a healthy shake-out in the marketplace, but those of us who see the real promise of disease management also fear that the coming backlash will go too far.
#1 by Dan Ross on April 30th, 2007
Dr. Coulter has hit the nail squarely on the head. The MCOs are very guilty of promoting this “vapor” process of DM. One nurse per 20,000 to 25,000 healthpln memners? Our system is fragmented by design and produces a tremendous volume of human suffering and financial waste. Mailing diet books to diabetic members while requiring Rx co-payments in the $300 monthly range dosen’t provide “care”. Congrtulations, Dr!
#2 by Dr.+Christopher+Coulter on May 9th, 2007
It would be bad enough if it were just “vapor” disease management, but what makes it even worse is the breach of trust with employers and their health plan participants. Disease management is promoted to employers with stories about the impact disease management nurses have had on people’s lives, and rightly so. But it is cynical and short-sighted to take advantage of benefit managers who may not have enough health care expertise to realize they are being short-changed, and to deny needed help to their beneficiaries.