MANAGED CARE February 1999. ©1999 Stezzi Communications
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A disease management program by any other name might go belly up -- pronto. But there are ways to avoid the quick fizzle.

The Short, Unhappy Lives of Too Many DM Programs

By Frank Diamond
Senior Editor

The best-laid plans of HMO executives can fizzle -- especially if those plans involve disease management. Every year DM programs are launched and quickly die. Nobody knows just how many go belly-up, but anecdotal evidence abounds that it happens a lot. Even diehard DM advocates admit that many programs are erroneously slapped with a DM label and have the shelf life of a celebrity marriage.

"The reason that many so-called disease management programs fail is that they are not true disease management programs to start with," says Stan Bernard, M.D., M.B.A., principal for health care industry consulting at A.T. Kearney. "They are what I call intervention management programs, such as clinical guideline or patient education programs, instead of a coordinated set of interventions seen in most successful disease management initiatives. When true disease management programs fail, it is usually the result of poor physician buy-in and ineffective execution."

However you define disease management, implementing a program can be difficult, notes Al Lewis, president of the Disease Management Purchasing Consortium, who adds that quick fizzles happen all the time.

"The people who contract for the program at the health plans do so under pressure to get the job done quickly, or without a budget, or they contract with a vendor they've used for some other purpose and that vendor has offered to give them three months for free," says Lewis.

One health care consultant says that the bidding process can be tricky and suggests that HMO executives closely review the data on which the vendors set their benchmarks. "What happens is the vendor will make predictions based on clinical trials or on programs that were launched in highly controlled managed care environments," the consultant says.

Most experts contacted agree that problems can arise in the bidding process. The notable exception is Lewis, who says that he's "never seen a program fail because a competitive bidding process was done wrong."

Vince Kuraitis, J.D., M.B.A., a principal in Better Health Technologies, a consulting firm, says that it is during bidding that a vendor may be tempted to say that he can deliver measurable results in one year, when it may actually take two or three.

"We advise our clients to look for a three-year contract," says Kuraitis. "The vendors need this time because much of the cost of DM program implementation is front-loaded. The plans need to have a longer perspective, too. Disease management should not be viewed as a quick fix."

And how fast can the programs fizzle? "I've seen it where they can't even get off the ground," says Lewis. "They can't enroll the patients."

Of course there are the usual suspects: lack of physician buy-in, patient compliance, and information technology.

"The most likely scenario for a quick failure is one of passive resistance in which the local doctors say the program is just nonsense," says Kuraitis.

Regarding patient compliance, Kuraitis holds out some hope that technology may provide assistance. He talks about three-button telephones developed by SOS Wireless that can be used by patients with congestive heart failure who don't want to be too far from help. "Heart patients want some way to access the specialist 24 hours a day," says Kuraitis. "Technologies are under development that will allow them to carry around a combination telephone, pager, and Internet access device."

Make sure the vendor has a good track record in managing the specific disease you're interested in managing. And make sure he has all the tools to do the job.

"A lot of times vendors that are good at one aspect of disease management direct all their resources into that one aspect to the exclusion of everything else," says Lewis.

Louise Kier Zirretta, M.B.A., group vice president at Isis Research, and author of the Disease Management Strategic Research Study & Resource Guide, says that if quick fizzles do occur -- and she hasn't seen any numbers that would identify a trend -- "it might be because you have a disease management program in place for a population you don't serve any longer."

Kier Zirretta notes that about 20 percent of the 367 HMOs that participate in Medicare bailed out of the program at the end of last year. "Anything they were doing in the area of congestive heart failure is not going to have the same emphasis," she says.

From scratch

When Peter Katona, M.D., medical director for Apria Healthcare, is asked to give advice about launching DM programs, he says simply, "Do your homework." He should know. Several of Apria's DM programs died last year. (See "Home Health Care Company's Experience Shows How Easily DM Programs Can Fizzle".)

Janine Evans, M.D., medical director for Yale-New Haven Hospital IPA-PHO in Connecticut, has been doing a lot of homework recently. Evans hopes to spin DM programs out of Yale-New Haven's ambulatory case management program, which was created four months ago. Using mailings, phone calls, and physician feedback, Evans's team is gathering and reviewing clinical and pharmacy data to determine what groups to target.

The case management program at the 45,000-member IPA-PHO was put in place to address some resource-use concerns immediately. Creating the official DM programs will come later -- within the next year. But some form of disease management is already under way. "We want to reduce the requirement or need for high resource use in our patient population," says Evans.

She has not yet chosen which diseases to manage in the official programs but the main candidates -- not surprisingly -- are coronary heart disease, congestive heart failure, diabetes, asthma, and obstetrics. She wants to remain flexible.

"We have Medicare and Medicaid members, and we have members who are part of commercial plans," says Evans, who points out that about 1,000 physicians belong to the IPA-PHO. "We want to structure our programs around the many variables in each of these populations."

Evans says another way her team is trying to avoid the quick fizzle is by devising easily recognizable and agreed-on measurements for success. "Those measurements will reflect the financial realities as well as patient and physician satisfaction," Evans says. "The results will help us prove that we're achieving the goals we promised when we presented the program to our board of directors."

Diane Collins, R.N., one of Evans's ambulatory case managers, notes that the team has traveled far in a short time. "We started with a piece of paper and a pencil," says Collins. "We put together the entire database -- the backbone. Our biggest stumbling block was identifying the patients. It was a large number of patients and only four of us. We contact them by phone and we also go and visit them. We call them up right after they go home. We're just really feeling our way through."

Despite the danger of a quick fizzle, there is some margin for error, Kuraitis suggests. He relates a story of a vendor who admits privately to "totally screwing up the implementation but the program still showed a 50-percent decline in readmissions."

"It is representative of the power of disease management," he says.

"This stuff really works."

Home health care company's experience shows how easily DM programs can fizzle

Don't mention home health care companies and disease management in the same breath when you're talking to Al Lewis, president of the Disease Management Purchasing Consortium. In Lewis's opinion, home health care companies -- with the exception of Caremark and Matria -- have had very little success with disease management. "They don't even take the time to try to understand it," says Lewis. "Disease management is vertical and home care companies don't sufficiently realize what else is needed."

You want names? Lewis mentions Apria Healthcare. "It seems that Apria was getting a lot of bids but couldn't collect the data to make the programs really take off," says Lewis. "Apria did not provide physician education or outbound education calling. Of any five people in a disease management program, only one is sick enough to need a visit. A couple of companies joined the consortium because they didn't like how they came to choose Apria."

Peter Katona, M.D., Apria's medical director, says that DM programs operated by that company fizzled for a variety of reasons, but the main cause was lack of funding.

"The company was having many financial problems and it gave DM programs a low priority," says Katona, who adds that he was primarily involved with the HIV program. Other programs that were launched and that subsequently fizzled in 1998 -- after about three years in operation -- were asthma and COPD.

"It seemed to me that HIV was a very worthwhile program," says Katona. "Three physicians were doing it through a provider entity. Both physicians and patients felt it was productive for them." Apria hoped to reap financial benefits -- but only in the long run. "It wasn't intended to be financially successful for Apria in the short run."

Watch those contracts

It certainly wasn't out of the red before another problem cropped up.

"The large group in San Francisco that bought the DM program for the three physicians to run took what we had and set it up itself," says Katona. When asked how someone could get away with such maneuvering, Katona states: "Apria was naive in not anticipating that its program could teach the user to run it himself. We felt that we could do it better, and that the contractor didn't have the resources to do it well on his own. We also made mistakes with our contracting."

Other Apria DM programs suffered setbacks as well. "Apria officials made some mistakes in purchasing an educational package for asthma that did not do what they were hoping it would do." That package contained mostly videos and brochures, says Katona.

That wasn't all. "I'm a big believer in database management," says Katona. "Apria is steadily trying to become more and more effective as a data manager. It was very difficult to assess the effectiveness of the programs and, thus, hard to sell them."

For other organizations hoping to get into disease management, Katona has this advice: "Know what's needed. Know what you can do, and periodically reassess your effectiveness both clinically and financially."