By John P. Geyman, MD
Annals of Family Medicine
Disease management is being promulgated by many policy makers, legislators, and a burgeoning new disease management industry as the next major hope, together with information technology and consumer-directed health care, to bring cost containment to runaway costs of health care. Many expect quality improvement as well. The concept is being aggressively marketed to employers, health plans, and government in the wake of managed care’s failure to contain costs. There is widespread confusion, however, about what disease management is and what impact it will have on patients, physicians, and the health care system itself. In this article I give a current snapshot of disease management by briefly addressing (1) its rationale and growth, (2) its track record concerning costs and quality of care, and (3) its impacts on primary care.
There are two basic types of disease management programs–those based on primary care and integrated within a managed care organization (eg, Group Health Cooperative and Kaiser Permanente), and commercial vendors to which employers and health plans may outsource their disease management functions. The former has been well accepted within the medical community as an important advance in the care of chronic disease. Group Health Cooperative and Kaiser Permanente have pioneered new approaches to chronic disease management based upon a new paradigm, the Chronic Care Model. For example, primary care teams are provided support in the form of electronic diabetes registries, evidence-based guidelines, patient self-management support, and decentralized on-site consultation with a diabetes expert team (a physician and a nurse specialist).
Commercial disease management programs are quite different. As carved-out programs, they are not integrated with primary care, are for-profit ventures, and are marketed to employers and health plans primarily as a cost-containment strategy. With sophisticated information systems, disease management companies focus on patient education and more-effective patient self-management, especially by use of telephone calls, mailings, and the Internet. Commercial disease management programs often provide minimal communication with primary care physicians, and reception of these programs by physicians is frequently antagonistic. Physicians may at times receive telephone calls from several nurses in distant call centers about the same patient with multiple chronic conditions.
Disease management on a Chronic Care Model based in primary care is an important advance in the care of a growing part of the population. With training, reengineering of practice functions, and adequate funding, the elements of this model can be adapted to many primary care settings, as Group Health Cooperative has already shown in many community health centers across the country. With a strong link to primary care, quality of care can be improved, but cost savings cannot be assumed. Costs may actually increase as better quality of care is provided to patients previously undertreated for chronic conditions. There is no solid evidence yet that commercial for-profit disease management vendors will save money and improve care of chronic illness on a long-term basis. It is much more likely that the current enthusiasm among employers and insurers for outsourced disease management programs will end up as just one more policy failure, undermining primary care and delaying increasingly urgent health care reform.
By Don McCanne, MD
This article could not be timelier. In response to growing concerns about the affordability of health care, the political arena is awash with proposals to control health care spending. Unfortunately, because of the timidity of the politicians in confronting the powerful vested interests that are wasting so much of our resources, they are turning to pseudo-solutions such as the commercial variety of disease management.
The private health insurance industry has been aggressive in its marketing of innovative products that shift risk from insurers to taxpayers and to patients with greater health care needs. While abandoning the risk pooling function, they have been selling us more and more administrative services. The commercial disease management programs compound this administrative waste, while introducing yet another disruptive, intrusive element into the clinical arena.
Yet the deficiencies in chronic disease management are very real. But rather than wasting more resources on third party managers, the solution is to reinforce our rapidly deteriorating primary care infrastructure. A strong primary care base provides the ideal environment in which to develop an effective chronic disease model. Barbara Starfield and others have demonstrated that this would not only improve quality of care, but would also address the issue of affordability by ensuring more cost-effective care.
To accomplish this, incentives need to be realigned to encourage the improvement and expansion of the primary care infrastructure. This would be a simple task for the public administrators of a single national health insurance program. Crafting reform that leaves the private insurance industry in play would only direct more resources to their primary product: ever more wasteful administrative services. We need to take care of our patients, not our insurers.