MANAGED CARE March 2010. ©MediMedia USA
Disease management should be a function of primary care, some industry proponents argue. Did someone say patient-centered medical home?
Nothing bolsters the reputation of a consultant more than making a prediction that turns out to be true. Under the Medicare Modernization Act of 2003, the Centers for Medicare & Medicaid Services launched eight disease management pilot programs throughout the country. Ariel Linden, DrPH, MS, president of Linden Consulting Group and a widely published researcher of DM outcomes, published a white paper in the spring of 2008 that explained why those pilot programs would fail.
“And shortly thereafter — guess what? — Medicare pulled the plug on them,” says Linden.
In that peer-reviewed article, titled “Medicare Disease Management in Policy Context,” Linden touted an approach by which “the primary care physician leads a team of specialists, nurses, dieticians, pharmacists, and health educators to provide and coordinate care for the ill population.”
An intensive approach emanating from a physician’s office is the only way that DM will work, Linden argues. “I mean there is nothing here that adds up unless you have this entire infrastructure and you are firing on all of your spark plugs.
“You need to have the medical group; you need to have the hospital associated with it; you need to have this whole infrastructure built around it; you need the information technology that will allow health information to be transferred between all the providers and participants. (For more about DM, see our cover story [1].)
“There must also be someone manning the phones reaching out to patients. There should be a pharmacist available to explain medications. A behavioral change expert and social worker must be involved also.”
Jodi Aronson Prohofsky, PhD, senior vice president for health management operations at Cigna, sees value in the push to make DM a function of the provider. She notes that Cigna is participating in several medical home pilot programs, including multipayer programs in Colorado, Pennsylvania, and Vermont, and it has a Cigna-only program in New Hampshire. She says that the pilot programs have yet to generate enough information about how worthwhile it may be to rely more on primary care.
Individual preference
“We completely agree with the concept,” says Prohofsky. “But I don’t know that the whole of the system we live with today is ready. We truly believe it should be the individual’s preference. I should be able to engage in the health care system any way I prefer. One option may be through my practitioner.”
Harvard Pilgrim Health Care strives to maintain good ties with physicians, ties that help with something as complex as DM, says Judith Frampton, RN, MBA, the plan’s vice president for medical management.
“We try to understand what would be most helpful to them,” says Frampton. “Some of them want online registries; some want things faxed to their office. So we’ll send, for example, something like, ‘Here are your diabetics. I use diabetics as an example, but it is the same for any condition. Here are the people who are overdue for X, Y, and Z. If we’ve got that data wrong, just correct it. And please put a check-mark if there is somebody you really want us to call.’”
Disease management needs to have the entire primary care infrastructure built around it if it is to succeed, says consultant Ariel Linden, DrPH, MS.