Congress gearing patient rights debate

The lesson from Medicare’s demonstration projects for disease management, according to the Congressional Budget Office, is that DM does not work. “In nearly every program involving disease management …, spending was either unchanged or increased relative to the spending that would have occurred in the absence of the program, when the fees paid to the participating organization were considered,” says the report “Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment.”

Some in the DM business, as might be expected, dispute the findings, saying that the study looked at programs that used antiquated methods.

The six demonstration projects involved organizations providing DM or care coordination to Medicare fee-for-service beneficiaries.

There were 34 programs operated by DM companies that provided services to insurers, employers, and hospitals and other providers.

“The programs used nurses as care managers to educate patients about their chronic illnesses, encourage them to follow self-care regimens, monitor their health, and track whether they received recommended tests and treatments,” says the report.

DM worked, in terms of outcomes, when there was “significant in-person interaction” between care managers and patients. However, the reductions in spending for such intense programs were “insufficient to yield net savings….”

Randall S. Brown, an expert in health care services at Mathematica Policy Research, was asked to review the study. “The evidence that we’ve looked at is that large-scale telephonic disease management doesn’t work.”

Brown continues, “Think about this for a moment. Suppose you’ve got somebody who has four chronic diseases. A phone call from somebody he doesn’t know is supposed to get him to quit smoking, lose weight, take the medication on time? The person who is doing the calling typically isn’t connected to the member’s physician. Is it a big surprise that it doesn’t work?”

For the government, in terms of telephonic DM, Brown adds that “the nails are in the coffin. I can’t speak for CMS but every demonstration that we’ve done for them on telephonic disease management failed. It showed no savings.”

The CBO’s report was just one reason that there have been some “is disease management dead?” discussions going on.

Gordon Norman, MD, MBA, chief innovation officer at Alere, a DM vendor (Norman prefers “population health management”), says the CBO study is flawed on many levels.

“The CBO study was instructive for what it was,” says Norman. “But we need to note some important caveats that affect the interpretation of this report.” They include:

  • The programs studied are old and things have changed. A number of the studies examined by the CBO took place a very long time ago; there are no programs today that look like the programs of 15 to 20 years ago.
  • Programs are hard to compare. There is an implicit assumption in evaluating many DM programs, as the CBO did, that these programs are static and monolithic — as though we were studying a new drug, for instance. Conducting a DM program is not the same as a drug trial where the patients are heterogeneous but the drug always remains the same compound.
  • The population in the CBO study — Medicare fee-for-service — is unique. It is dangerous to take findings from studies looking at DM experience in Medicare FFS and extrapolate those results to DM’s effect on other populations.