Cover Story
MANAGED CARE May 2004. ©MediMedia USA
Finally, it seems that there is a way to manage patients with multiple chronic conditions properly. Understanding and technology converge.
It's as if that relative — the one who people thought would never be able to hold down a job and who long ago packed his belongings into a 1958 Edsel and sputtered off toward the sunset — suddenly came roaring back behind the wheel of a 2004 Rolls Royce.
No, no, that's not it. It's really one of those things, ideas, theories, systems about which people say that it's not as if it had been tested and failed but rather that it had never been tested at all.
Care coordination — which, for the purposes of this article, means optimal management of people with multiple chronic diseases to improve outcomes and cut costs — just suddenly seems a lot more doable, says Peter Kongstvedt, MD, a partner in Capgemini, just recently renamed from Cap Gemini.
"That's because of the interventions we now have available," says Kongstvedt. "So when people have these multiple chronic conditions, we're able to do much more to them than ever and they live longer."
This opportunity must not be wasted.
"Coordinating the care of the small percentage of patients with multiple chronic conditions is the number one priority of medical managers in health plans today," says Kongstvedt.
Ka-ching!
And for those who must look to the bottom line and whose antennae are already tingling because this sounds like it can cost a whole lot, there's more than consolation to be mined.
"Think about it," says Victor Villagra, MD, the president of Health & Technology Vector, a consulting company specializing in disease management. "If you coordinate chronic care you avoid duplication of tests, you avoid errors in prescribing medications. You augment the effect of medications that may be indicated for two conditions at the same time, and there are many examples of those. So, the potential to reduce costs, reduce errors, enhance efficiency, and enhance health outcomes is substantial."
The National Committee for Quality Assurance is taking notice.
"We're beginning to get some evidence that those patients, when their illnesses are well controlled, don't cost us as much," says Greg Pawlson, MD, MPH, the NCQA's executive vice president. "At least there's some indication that there's a payoff. And of course that starts to get purchasers interested, especially the large self-funded employers, since they're paying out billions of dollars a year to take care of these patients."
Disease management
Everyone agrees that disease management is integral to this effort.
"One of the most important developments is the growth of disease management programs that are multidisease on a single platform," says Villagra. "That's the most important development. DM companies have evolved from disease-centric organizations to more patient-centric organizations."
In the early days of disease management, programs and even companies bore the names of the particular disease that they focused on.
"For example," continues Villagra, "the Diabetes Treatment Centers of America, which is American Healthways today, specialized in diabetes. Cardiac Solutions, now CorSolutions, specialized in heart disease. AirLogix specialized in respiratory. You can see how the names of the companies implied their original expertise."
These companies have evolved and expanded their clinical offerings to include other chronic conditions that affect their patients and by doing that confront a problem that has long been with us.
In a study that was published in Health Affairs in March/April 2001, Marc L. Berk and Alan C. Monheit say that despite attempts over the past decade to control rising costs, "relatively little effort has been targeted toward" the top utilizers. (See "The Big Drain".)
"Although managed care has had an enormous impact on the health care delivery system, we see relatively little change in the way it has affected the aggregate distribution of resources among those who use the most services," says the study. "There are serious limitations to the effectiveness of any cost containment strategies that focus on the 90 percent of the population that collectively accounts for only one third of total U.S. health care spending. Accordingly, further efforts to reduce costs will require difficult choices about the level of care provided to those with the greatest need."
The Institute of Medicine suggests that those choices might be made more easily with the help of care coordination. "For several decades, the health care needs of the American people have been shifting from predominately acute care to chronic care," the IOM pointed out last year in Priority Areas for National Action: Transforming Health Care Quality. "Today, chronic conditions are the leading cause of illness, disability, and death in the United States.... The nation's health care delivery system has not significantly evolved to meet these changing needs.... [C]hanging the health system will require breaking down boundaries between diseases as well as classes of diseases...."
The IOM goes on to note that approximately 20 million Americans with chronic disease receive contradictory information from different health care providers, and 17 million report being told by their pharmacist that the drugs they were prescribed could have harmful interactions. Clearly, we are not all reading from the same page.
Sins of omission
There are sins of commission and sins of omission, says Charles M. Cutler, MD, MS, the national medical director for quality management at Aetna. "When we think about care coordination, what we think about for the most part are sins of omission, what's not getting done for patients that, if it were done, would bring about a better outcome." Making it work means adopting a proactive mind set.
For instance, patients with heart disease are often prescribed nitrates to treat angina. But if another physician comes along and prescribes Viagra, which you should never use with nitrate, properly rendered care coordination would flag that contraindication: Physicians would be notified, prescriptions adjusted or rewritten, and case managers would be alerted.
"I think the table is set for a much more sophisticated and integrated approach that includes not just the health care benefits but benefits across multiple and distinct product lines," says Cutler. (For more on this, see "Program Puts Disability, Health Managers on Same Team,")
The example of Viagra and nitrates is not simply a theoretical calculation, Cutler adds. "We got a letter back from the doctor saying: 'Thanks so much. I never would have known about this and now I'm able to make sure the patient doesn't have these complications.'"
This is clearly much broader than classic disease management, which is usually understood to mean having treatment protocols that are specific to a certain disease.
The same puzzle
"The things we're talking about aren't necessarily disease-specific but have more to do with coordinating care where there aren't specific guidelines," says Cutler. "To me these are all parts of the same puzzle and you just need different pieces to solve it. So for some things, the DM approach works well. For some other things, a system with algorithms to identify these kinds of drug interactions works well.
"Where there aren't specific guidelines." Funny Cutler should say that.
Villagra champions what he calls "meta-guidelines," which attempt to integrate guidelines for multiple chronic conditions. He cautions that meta-guidelines are not formal documents yet, but he hopes that one day they will be.
"For example," Villagra explains, "there are no written meta-guidelines that give physicians assistance in helping to manage a patient with diabetes, heart disease, depression, and emphysema."
Often, Villagra says, clinical symptoms, diagnostic workups, and treatment plans for one condition are modified by the other. "They sometimes even cancel or reinforce each other, making care coordination a very complex activity," says Villagra.
Diabetics, for example, are more likely than the general population to have had silent heart attacks and not know it because there was no chest pain. Also, target blood pressure levels for patients with heart disease and diabetes are supposed to be lower.
"Disease management programs have almost inadvertently slowly been integrating separate guidelines," says Villagra. "The nurses who talk to patients with all of these diseases have the guidelines embedded in their decision support tools. Good primary care physicians who keep their knowledge current integrate that information in their heads, but it is hard to do it consistently. Disease management now monitors more and more conditions, or at least the most important chronic conditions that cluster in the same patient. This is a major operational advance, and as organizations see the benefits of integrated patient-centric meta-guidelines, they may be formalized as written documents or, more likely, software."
But haven't we been down this road before? The assertion by Villagra and others that coordinating the care of those with multiple chronic disease will save money in the long run is met by healthy skepticism in some quarters.
Challenges
"The problem is that the program's value is intuitively derived — it makes sense, doesn't it, to have a nurse call you up and coach you through your illnesses — but the economic/financial return has yet to be conclusively demonstrated," says Jaan Sidorov, MD, the medical director of care coordination at Geisinger Health Plan in Pennsylvania.
That hinders attempts to give care coordination top priority because, as Sidorov says, the medical managers need to convince the accountants that allocating resources to this population will improve the medical loss ratio.
"The interesting thing here is the plural nature of illnesses," says Sidorov. "The disease management organizations and MCOs that do DM themselves have discovered that they can't restrict their programs just to one disease. The nurses need to be facile in helping this population deal with the primary disease and co-morbid conditions."
Sidorov does acknowledge that disease management is evolving. "It's not only taking on more members and more diseases but also dealing with more illness in the diseases that they do manage," he says.
More surprising is the caveat raised by Al Lewis, president of the Disease Management Purchasing Consortium International, who has been perhaps the most visible advocate of DM. He questions the underlying assumption.
"The idea is an excellent one, but you need to temper your expectations of what's achievable through care coordination," says Lewis, who calls such expectations a classic fallacy. "People think that because 5 percent of the population accounts for 55 percent of the spending that all you need to do is focus on that 5 percent and that will magically save you money."
Take a good look
Dig a little, Lewis says, and you'll find that that's not the case.
"Number one: A huge percentage of them are not the same in one year as they are in the other," he says. "So they might have accounted for 55 percent last year, but a lot of that is going to be transplant, trauma, neonatal, that kind of thing. Number two: Those who really are sick often die before they get help. Number three: A number of people are that expensive because they're on high-cost drugs because they have rare diseases. And then by the time you get to the ones you can intervene on, you're talking about people who have reasonably severe cases of chronic diseases, and you end up being able to save roughly 1 to 2 percent of the total health care plan's spending."
While not exactly contradicting Lewis, Berk and Monheit in their Health Affairs article do suggest that you might be surprised by the demographics of high utilizers.
They warn that their study "should not be equated with discussions about expenses incurred during the last year of life and how many resources should be spent on people who are unlikely to achieve a high quality of life even with access to high technology." They continue: "The high-expenditure population may be younger and in better health than some might expect.... Thus, the majority of persons in the highest 1 percent of spenders are not elderly. Furthermore, most of the highest 1 percent of spenders do not consider themselves in fair or poor health."
What perhaps remains the most daunting challenge in care coordination has been a question dogging disease management from the beginning: Will physicians support it?
Pawlson, of the NCQA, says that care coordination has historically been overlooked by physicians.
"In medical school we are taught to think about episodes, which are mostly visits; we are not taught to think about what happens between visits or how patients might interpret or misinterpret what we tell them," says Pawlson. "What happens when they don't — or can't — apply what you talk about between visits?"
Kongstvedt agrees that care coordination often stumbles in the physician's office, where the computer age has yet to fully dawn.
"Doctors are sort of the great frontier of connectivity," says Kongstvedt. "It's hard enough to get them to do electronic claims let alone to do other business functions electronically. Everybody wants that."
"Everybody" includes the IOM, whose 1999 Crossing the Quality Chasm called for eliminating "most handwritten clinical data by the end of the decade."
That's not happening, says the New York Times, which reports that less than 1 percent of U.S. private hospitals have fully met the requirement of the Leapfrog Group that 75 percent of a hospital's doctors order prescriptions and tests electronically.
In fact, physicians can be downright obstructionist about new technology. At Cedars-Sinai Medical Center in Los Angeles last year, physicians complained that a new computer system proved to be "too great a distraction" and they forced its withdrawal.
Hassle factor
Kongstvedt, author of Capgemini's Balancing for Success 2004: The Top Ten Issues Facing the Managed Care Industry, writes: "At the same time that advanced disease management (DM) is showing improved results in cost, quality, and member satisfaction, physicians are beginning to push back. One major complaint is that of being called by multiple DM vendors during the day. They see a lack of coordination as well as an increase in 'hassle.'"
But, argues Villagra, true care coordination will help to cut back on that hassle — for the patient as well as the physician. It means that members do not depend upon a 10-minute interview with a primary care physician to obtain all the information they need.
"Now thousands — probably millions — of patients are receiving information of outstanding quality," says Villagra.
Cutler, of Aetna, hopes that the programs will make it easier for physicians by taking the administrative aspect of care coordination out of doctors' hands.
"The kinds of things that I'm describing, we're actually not asking the doctors to do," says Cutler. "We're providing that coordination through our own nursing staff. So, the doctors love the fact that we could make sure that the patients are getting the medicines that they need and the durable medical equipment that they need and that we prompt them for that follow-up medical appointment.
"These are things that doctors would have trouble doing on their own, even if they weren't busy. These kinds of things complement the physician's practice. Some of these activities actually help doctors decrease their malpractice exposure and decrease the kinds of things that they're trying to avoid in their practice."
Questions on quality
What may push physicians further along, says Pawlson, is the new focus on variation in quality that is being documented by researchers such as John Wennberg, MD, director of the Center for the Evaluative Clinical Sciences (CECS) at Dartmouth Medical School and principal investigator of the Dartmouth Atlas of Health Care.
"Your choice of doctor, hospital, and health plan has a huge impact on whether or not you get care you might need," says Pawlson. "Your next-door neighbor could easily have a 50 percent better chance of getting care that you both need. That level of variation is unacceptable. And the problem only gets worse when a person has two or three chronic illnesses — there aren't any guidelines for treating a manic-depressive diabetic with high blood pressure and cholesterol."
Perhaps what will make care coordination work this time is the interest that employers are showing.
"I think businesses have two options for dealing with rising costs," says Pawlson. "They can either throw up their hands and run, which some have, or they can roll up their sleeves and say, 'You know, let's flex our muscle and buy health care the same way we buy everything else — based on value.'
"We've known for a long time that doctors aren't a commodity, but we're still paying them like they are," says Pawlson. "It's no wonder the market doesn't work."