Irresistible Force Called DM Facing Some Immovable Objects


Al Lewis

The young industry must clear some hurdles in the near future. Medicare stratification, disability management, and federal restrictions are worrisome. Then there’s that new law in California.

To paraphrase the immortal words of Dan Quayle, there is an irreversible trend toward more disease management — but that could change.

All the DM pieces are starting to fall into place. Health care professionals and employers are beginning to understand the economics and the quality-of-care benefits. Vendors are getting more experienced and buyers are developing better information systems, which they need. The stage is set for explosive growth and I predict DM will be the fastest growing non-Internet sector of the health care industry. That’s the irreversible trend.

Now for the “that-could-change” part. There are some legislative and regulatory movements on the horizon that pose very serious threats. In some states, identifying patients through claims is going to become impractical if not de facto illegal. I’m especially worried about Texas, Pennsylvania, and Massachusetts. Those are the three I know about, but there are probably others.

In a very small state called California, there’s a new law that says patients can only get into disease management programs if physicians enroll them.

The debilitating provision in the approximately 35-page statute is only a paragraph long. It states: “For purposes of chronic disease management programs, information may be disclosed to any entity contracting with a health care service plan to monitor or administer care of enrollees for a covered benefit, provided that the disease management services and care are authorized by a treating physician.”

As anyone in the industry knows, physicians are often part of the problem. The many who are not adhering to protocols or guidelines will resist efforts to enroll their patients in programs.

Battle plans

Jim Jacobson, J.D., of the Washington law firm of Gardner, Carton, & Douglas (and who also serves as general counsel for the DMAA), says there are several ways to fight this though none of them seems terribly promising at this point.

The industry can hope that Congress passes a less onerous patient-privacy law, but don’t hold your breath. In addition, while the DMAA has done a good job in getting Congress to credit its reasons why disease management needs to be protected from privacy legislation, the Department of Health and Human Services is another story altogether.

Jacobson says that privacy guards favored by Secretary Donna Shalala are likely to be far more stringent than legislation on Capitol Hill.

He feels that the industry’s best bet may be to lobby for legislative repeal at the state level — another long shot. Meanwhile, it will be tough to prove any bad effects the legislation may have to legislators in other states that are considering a similar move.

“It’s difficult to show factors resulting from a lack of access,” says Jacobson. “That’s like trying to prove a negative.”

At federal level

The huge issue is Medicare stratification, in which the government would pay more to health plans that have sicker populations. This sounds terrific in theory. In practice, however, they’re basing level of sickness on utilization. So if you’re a health plan doing a good job with disease management to the point where utilization goes down, your reward from the government will be less reimbursement.

Hopefully, the Health Care Financing Administration will improve those systems and stratify based on underlying medical conditions, as opposed to the amount of utilization.

I’m considerably less worried about federal confidentiality rules. Congress has been educated on the importance of carving out disease management from confidentiality legislation.

Falling into the irreversible-trend category will be a push by HCFA for a DM program that covers Medicare fee-for-service members. That would be terrific. But so far, to paraphrase Woody Allen, it’s just a notion trying to find funding to turn into an idea and, eventually, a concept.

Internet’s potential

It’s on everybody’s mind these days. I predict that the Internet, as a data-gathering tool, will become an integral part of disease management, but it — in itself — will never become disease management. DM is too high-touch. There’s too much relationship building and coordination involved to be done without some labor components.

You couldn’t operate a DM program on the Internet anymore than you could have a third-grade teacher replaced by someone on the Internet.

Disability management

Some large self-funded employers are exploring ways to combine utilization management, disease management, and disability management. They’re wasting time and resources. Disability management is basically a method for pushing people back to work sooner without trying to improve their health status.

Disease management, on the other hand, actually improves the underlying health of these workers so that they’re going to have less lost-work time, lower medical expenses, and less need to use high-cost parts of the system.

Al Lewis, one of the nation’s foremost experts on disease management, is president of the Disease Management Association of America.

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