IT strategies that nudge patients into making healthier decisions may be labeled "disease management," "care (or case) management," or "medical management." Regardless, that concept is being applied in increasingly varied ways to an increasingly broad range of conditions. As the cost of treating chronic conditions increases, it seems only a matter of time before a care management approach becomes the norm, not the exception.
"The line between disease management and case management is blurring," says Peter Kongstvedt, senior executive in the Health & Life Sciences practice at Accenture, NYC. "Disease management has focused on fairly well defined diseases—congestive heart failure, diabetes, and so forth. In case management you're focusing on anyone with an expensive condition, which could include trauma, premature birth, AIDS, or cancer. The people who do case management—which occurs most often within health plans—are looking at the techniques that disease management uses and applying them."
Vince Kuraitis, a principal with Better Health Technologies, Boise, Idaho, notes that in December 2004, the Centers for Medicare & Medicaid Services (CMS) announced nine awardees for Medicare Health Support projects (formerly called the Chronic Care Improvement Program). All but one award went to large insurers and disease management companies, including American Healthways, Nashville, Tenn.; Lifemasters, Irvine, Calif., and McKesson Health Solutions, Newton, Mass.
"The message I see from these choices is that CMS values the ability to scale up and [is] looking ahead to millions of Medicare beneficiaries needing the services," he says. "This raises a larger question whether in the long run disease management is a carve-out from the larger delivery system or just becomes blended into what healthcare providers do."
Chronic disease management is receiving more attention as certain conditions become more common: People are now living longer with conditions that once cut lives short. "It goes all the way from people with diabetes to outpatients with HIV and some cancers," says Scott Young, M.D., director for health information technology with the Agency for Healthcare Research and Quality, Rockville, Md. "We want to know the best way to integrate what's known with what occurs in the physician's office—and at home. We're not just talking about smart systems, but smart systems that have to be connected to multiple providers. And that same capacity has to extend out to the patients themselves."
Modeling the future
Designing smart chronic-care management systems involves first deciding which patients should be targeted for clinical intervention. Finding high-cost patients is easy. Finding high-risk patients is somewhat harder but well within the capabilities of statistical analysts. Marilyn Schlein Kramer, president of DxCG, a Boston-based firm specializing in predictive modeling, notes that models based on claims and other administrative data are constantly improving, enriched by laboratory data and patient-reported information.
Models that watch for gaps in care (i.e., diabetics who ignore periodic eye exams) can help identify people who are not high-cost patients now, but are likely to become so in the future. The limits of this approach have more to do with economic incentives than with the models. "Clinicians certainly understand the idea of disease progression," Kramer says, "but it's hard for health plans to pay for possibly avoiding an amputation five years down the line."
CMS's Medicare Health Support is an ambitious effort to change this incentive structure. Participating firms have agreed to forfeit their fees if care costs don't drop by at least 5 percent for the entire target population, not just the subset of individuals selected for special interventions.
Kongstedt agrees it could act as an incentive. "Medicare could save money. The patients could be healthier. And disease management companies could have a new line of business."
The challenges center around convincing patients to improve behaviors—to take medications as prescribed, to modify diet/exercise habits, and to report relevant information promptly. Several vendors, including Health Hero Network, Mountain View, Calif., offer home monitoring devices that enable patients to self-report physiological data (blood pressure, blood glucose levels) and general changes in health.
Other organizations are looking at related issues: Robert Mechanic, director of the Health Industry Forum at Brandeis University, Waltham, Mass., describes growing interest in remote monitoring technology in support of home care and motivating patients. Mechanic notes specific interest in engaging physicians in disease management programs, often difficult because of skewed incentives under fee-for-service payment systems.
The forum has awarded a grant to researchers at Baltimore's Johns Hopkins University to study a program that combines pay-for-performance reimbursement with placing specially trained disease management nurses (their salaries paid by insurers) in five large private practices. Vendors are also looking at ways to make managing chronic care easier for physicians. Siemens Medical Solutions (Malvern, Pa.), now offers a product that creates a customizable call center within a physician practice, based on a combination of voice recognition software and alphanumeric entries from the patient's phone. Alan Barbell, who leads Siemens' disease management software line, says, "Physicians and hospitals are recognizing that even though the patient isn't right in front of them, they still can play a guiding role in making sure the patient stays on evidence-based guidelines to keep that patient out of an acute-care episode."
Technology reaches out
Eventually, the ubiquitous cell phone may prove to be the technology of choice in chronic-care management, says Peter Boland, a principal in BeWell Mobile, San Francisco. The firm believes that off-the-shelf cell phones equipped with patient-specific action plan modules could become pint-sized platforms for a steady stream of information between patients and provider systems. Prompts may include text messaging, buzzes, or beeps. Boland, summarizing results of this strategy abroad (primarily in Scandinavia), says, "People using this every day form a relationship with this device and use it to keep on track."
Implementing this degree of connectivity will require interoperability across numerous databases. Some say the formation of regional health information organizations (RHIOs) should speed this up as wider access to laboratory data will improve the precision of predictive modeling, and should enable faster action-plan responses to patients.
Naturally, advances based on remote health monitoring devices will introduce new problems. Kuraitis, an attorney, raises a critical issue: "Five years from now, a patient may be monitored in real time with an ECG. Suppose there's an abnormal heart rhythm. Do you send a home health nurse or suggest that the patient needs to go to the emergency room? The distinction between 'care coordination' and 'care' really begins to blur." Kuraitis suggests that for now, disease management companies may adopt a "defensive" strategy, trying to avoid liability by insisting on sharp distinctions between personalized health tips and delivering medical care. In time, he predicts, "Disease management companies will increasingly have to see themselves in the business of not only coordinating care, but providing care." This suggests that chronic care management programs and pay-for-performance initiatives will be joined at the hip. Keith Halleland, an attorney and principal at the Minneapolis-based Halleland Health Consulting, is wary of predictions but agrees that the "line between being a health educator and a health provider" is blurring. This issue, he adds, is complicated by laws that vary from state to state. "This is the new wave of medical management," Halleland says. "What I like about it is that it's more patient-focused. I think it needs to be better connected with providers. The companies that are doing this work will have to think harder about how their programs connect with the primary caregivers."
Fred D. Baldwin is a contributing writer in Carlisle, Pa.