Beware of pharmaceutical companies bearing gifts.
Logo-festooned notepads, coffee mugs and calendars may be the most obvious enticements drug companies hand out to steer prescription business their way. Increasingly, however, drugmakers are offering free services over trinkets to sell more pills.
Cost pressure on healthcare providers is translating into demands that suppliers justify the value of their products. That's where disease management comes in, a fuzzy term for the systematic integration of a host of treatment and prevention measures to improve patient outcomes.
By treating chronic diseases such as asthma or diabetes continuously and holistically, acute-care costs are supposed to be reduced while patient health improves. And the appropriate use of drugs in managing disease can optimize cost-effective treatment.
That's the theory, anyway. But the jury is still out on whether many of the add-on services from drug companies are valuable enough to influence purchasing decisions.
Nevertheless, tying disease management to product marketing has become the rage. And a host of pharmaceutical companies from Bayer Corp. to Zeneca Group have gotten into the act. In its simplest form, disease management promises to standardize treatment through protocols that improve clinical outcomes. Not surprisingly, a key component in many of the company-recommended disease management strategies is the use of their products.
Often, critics say, these freebie "value-added programs" are thinly veiled ploys to gain admission to an HMO or health system's formulary or boost a drug's sales.
With no strict definition of what constitutes bona fide disease management, the ambiguity in the field may benefit some companies' marketing efforts, several industry watchers say.
Prepackaged patient education programs or canned treatment pathways may be little more than "another form of sales and promotion masquerading as disease management," says Stan Bernard, M.D., a disease management consultant with A.T. Kearney, New York.
Marketing hype has soured some organizations on pharmaceutical company disease management programs.
"We steer clear of those," says Harold Sunderman, M.D., medical director of disease management for Lovelace Healthcare Innovations, a unit of Lovelace Health Systems, Albuquerque. "You just have to work on the assumption that anything developed by a drug company is subject to bias."
In fact, Lovelace has turned the tables by entering an agreement to develop disease management protocols in return for technical and financial support from Greenstone Healthcare Solutions, a wholly owned subsidiary of Kalamazoo, Mich.-based Pharmacia & Upjohn. Sunderman estimates early disease management programs cost about $500,000 to develop, with the costs slightly lower now that Lovelace has 18 under its belt. Greenstone then sells the disease management protocols to other healthcare providers and insurers along with consulting services, returning a royalty fee to Lovelace, Sunderman says.
To be sure, there is room for a wholesome alignment of drug company, provider and patient interests. Drugs often play a key role in managing a disease cost-effectively.
Yet, to realize disease management's benefits, providers need to implement a multifaceted approach, experts say. That's more than most prepackaged programs can deliver. Effective disease management is labor intensive, say those who have tried it. If straightforward patient or provider education could improve outcomes alone, it would have happened already, they say.
"To really do disease management, you have to touch patients," says Robert Stone, executive vice president at Diabetes Treatment Centers of America, a Nashville-based company specializing in improving diabetes care for HMOs and health systems. No amount of printed educational material for doctors or patients by itself will be effective in changing behavior, Stone and others say. That's why many simplistic programs often fail, even if the science underpinning them may be strong.
"The ultimate success of disease management turns on the ability to achieve patient compliance," confirms Ira Stundin, president of WellCare University, a think tank connected to WellCare Management Group, a Kingston, N.Y.-based managed-care company.
How then to separate the meaningful disease management programs from the rest of the pack?
First, look for a successful track record. Pitches for programs developed by panels of experts may look good on paper but have never been put to the real-world test. So even though disease management programs in many areas are new, you'll want to see data that show a candidate program has been successfully adopted elsewhere before you take the plunge.
Second, be very wary of free disease management programs bundled with product purchases.
"If someone's offering you a disease management program for nothing, they're selling you something else, and the cost is buried within it," says Stone.
Customizing and consulting are crucial, but they don't come cheap. Be prepared to pay for services, but make sure they are likely to deliver on worthwhile goals.
Blue Cross and Blue Shield of Florida's Health Options plans, for instance, turned to Diabetes Treatment Centers to provide diabetes management services among 200,000 enrollees in its central region around Orlando, about 4% of whom are diabetics. In the first phase, Diabetes Treatment Centers has guaranteed to save the plan the $750,000 cost of disease management services within 18 months and to share additional savings down the road. For Health Options the investment isn't cheap. Diabetes Treatment Centers' Stone estimates the cost at about $7 per enrollee per year for most plans. But the stakes of treating diabetic patients the same old way are high as well.
Although diabetics constitute about 4.5% of the U.S. population, they account for nearly 15% of healthcare costs, according to a 1992 study conducted by Lewin Associates that was supported by a grant from Diabetes Treatment Centers.
Already, diabetes management has reduced plan costs and improved enrollees' quality of life, says Joe Kocke, M.D., medical director at Health Options' central Florida unit.
"Over time we see more disease management rather than less," Kocke says.
What remains to be determined, Kocke adds, is whether Health Options will build such programs in-house or buy them. As providers and insurers develop expertise, the allure of outside programs, whether purchased or bundled free with product deals, is likely to fade.
"The pharmaceutical industry has had an important role in popularizing the concept, but the actual implementation (of disease management) is being carried forward by the managed-care organizations," says A.T. Kearney's Bernard.
With greater information and more direct access to patients, providers and payers are poised to take the leadership role in making disease management work. Their challenge is to avoid the image miscues of the drugmakers that have led the charge so far.