Precept Employee Benefits Blog

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

In the first three parts we’ve discussed the problems of finding all the potential candidates with disease management conditions among an employer’s beneficiaries, of getting coaching to a significant number of those identified candidates, and of demonstrating the financial impact of the program to justify the dollars being spent.  While these are the three biggest barriers to having an effective program and getting meaningful results, there are lots of secondary issues which can prevent an employer from realizing the potential value of a disease management program:

1. Clinical measures of improvement – we have noted the difficulty of calculating a valid return on investment and the delay of 18 months or so between the time that an employer starts paying for disease management services and when that employer can get a calculation of savings.  It is critical, therefore, to look at intermediate measures, and there are excellent ways to demonstrate the clinical improvement of the participants.  Diabetics, for example, should show improvement in their hemoglobin A1c levels as control of their blood sugar improves, should show better compliance with medications, and should have recommended testing for cholesterol, kidney function, and eye damage.  Improvement in these measures will predictably and reliably result in lower claims costs and better health outcomes.  Conversely, if there is no improvement in these measures, than any demonstrated “savings” will not be real.  Yet many disease management vendors omit this information or deliver it in a way that does not allow meaningful validation of their services.  If you don’t see a clinical improvement, don’t believe a vendors claim that they are saving money.
2. Failure to incorporate pharmacy data – disease management programs that rely only on medical claims information will not find most potential candidates and will overstate the savings generated by their programs.  Physician claims are notoriously inaccurate, since providers fill out forms to get reimbursed, not to provide accurate information.  Hospital claims are more valid, but they will identify only the sickest of the sick, leading to extreme regression to the mean and hugely inflated savings when it comes time to report return on investment.  Pharmacy data is essential to identify beneficiaries with asthma and diabetes, and to find heart disease and other diagnoses at an early stage.  Also, medication compliance is a critical element for controlling long-term costs, and if you are not tracking prescription utilization, there is no valid way to assess compliance.  If your disease management program does not incorporate timely pharmacy data, you will not have an effective program, although the return on investment report will look great.
3. Encouraging participation.  This is a difficult issue, because responsibility for getting identified candidates to accept coaching is shared between the employer and the program.  If employees are not familiar with the disease management program, they will be unwilling to participate, so employers must publicize the introduction of the program and assure employees that their medical information will not be available to the employer.  But even with good communication, only 20-30% of participants offered disease management coaching will accept it, in the absence of incentives.  Fortunately, sicker beneficiaries are more likely to accept coaching, and a sharp disease management program will make a second offer to a candidate who initially declined participation after that candidate has had a significant event like an ER visit or hospitalization.  But providing an incentive for participation, most often a modest refund of payroll contributions or other financial reward, will increase participation and improve program effectiveness.  Structuring such contributions to avoid HIPAA concerns and allow ease of administration can be challenging.
4. Coordination with other health plan programs.  Particularly when an employer contracts with a stand-alone disease management company, there can be conflicts between the disease management coaching and the health plan’s patient programs.  Case management is the most significant example, where beneficiaries with catastrophic illness like organ transplantation, cancer, and extensive rehabilitation have an intensive relationship with a health plan nurse.  It is clear that the nursing directives for such overwhelming illness must take precedence over routine coaching for diabetes or asthma, but often there is no connection between the clinical staffs at the two organizations to coordinate instruction and care.  Patients may be left confused, frustrated, and unwilling to participate in either program.  Similar conflicts can also arise with health plan activities including health advocacy, 24 hour nurse lines, and hospital preadmission and postadmission counseling.  It is an important and challenging to assure that the clinical staff delivering disease management services coordinates with other health plan services.

With all these ways that a disease management program can go wrong, it may be tempting to simply forget the whole thing.  That would be a mistake, given the potential for these programs to reduce medical claims, improve disability and productivity, and produce long-term health status improvement.  Good programs are available and vendors can be help accountable for delivering real results.  It is worth the effort.