However it's defined--whether as public health for profit or better outcomes for long-term savings--it's clear disease management is an idea whose time has come.
Preventing and controlling chronic disease in a population, the once unsexy hallmark of public health, has metamorphosed into disease management. That's a new title for making use of standardized care and prevention techniques.
In this era of capitated payments, disease management has impressed many medical leaders as a better way to cope with chronic disease than traditional take-'em-as-they-come medicine.
Although the disease management model has substantial potential for improving quality while cutting costs, estimates of how much quality and how much cost vary. Plus, there are significant start-up costs, such as big-time investments in computers and software.
Increasingly charged with caring for populations, physician executives at medical groups and integrated health systems are looking for effective
"Simply rationalizing and limiting utilization can reduce resource consumption, but I would argue that's a transient thing for a few, very smart people to retire on," Michael Alderman, M.D., says critically. Alderman is chairman of the department of epidemiology and social medicine at Albert Einstein College of Medicine, New York, and president of the American Society of Hypertension.
Thus far, Alderman says, HMOs have made their mark more by restricting care and selecting healthy patients than by applying medicine in a forward-looking way. But as managed-care market share increases, HMOs and other risk-sharers will become responsible for larger market segments and their usual practices will no longer be tenable.
"The challenge is to take pieces of a systematic approach and inculcate them into managed care," Alderman says.
Cardiovascular disease is emerging as a top target for disease management strategies. The cost of treating cardiovascular diseases of all kinds is expected to exceed $91 billion this year, according to the American Heart Association.
As harbingers of more serious and costly conditions, hypertension and congestive heart failure, in particular, are getting a lot of attention. By treating these diseases as early as possible, physicians not only can prevent more expensive acute interventions but also can dramatically improve patient satisfaction.
"For some conditions, like cardiovascular disease, we know a whole lot about what works and how to prevent progression from one stage to another. When you organize the care to eliminate variation and provide optimal care, outcomes improve," Alderman says.
Alderman speaks from experience. He has guided a workplace-based hypertension management program in New York since 1973. The program has achieved lasting hypertension control and a 40% reduction in related diseases in nearly 80% of the more than 8,000 patients treated.
Bringing medicine to the workplace combined with aggressive case management has turned out to be much more important than using the latest drugs, Alderman says.
"Pharmacology of the process is not what this is about," he says. "It's about the delivery system."
Segmenting the patient population by a half-dozen risk factors, including history of diabetes, stroke and heart attack, to concentrate on high-risk patients is proving most successful, he says. "We've got to get over the idea that we're trying to lower blood pressure (alone); the goal is preventing strokes and heart attacks."
For the highest risk group, a 40% reduction in cardiovascular events means preventing five heart attacks or strokes per 100 people per year, Alderman says. "Your payoff over a five-year period is really enormous."
But turning a theoretical disease management scheme into real-life practice is harder than it looks. Beefing up information systems to implement a program on a large-scale basis is expensive. And making disease management work, even in a pilot program, requires a redefinition of physician roles and a reordering of the delivery of medicine. Typically, every significant change comes with a struggle over who gets paid for what.
Each of these obstacles helps explain why disease management isn't the norm in most places. Redefining physician roles, making teamwork a reality and imposing a healthy measure of standardization are important tasks in the implementation of any disease management program, tasks that demand the leadership of a highly motivated physician executive, someone with long-term vision.
"Everything in the market points to a strategic advantage for organizations that can pull this off," says David Shulkin, chief medical and quality officer at University of Pennsylvania Health System, Philadelphia. But, he concedes, results will take time and money. Penn, which owns or manages group practices with 350 primary-care doctors, has 40 separate disease management plans under development. Ultimately, 80% of the system's patients will be managed this way, Shulkin says.
As a strategy with long-term potential, the disease management model requires as much faith as financing at the start. "We are not looking at a short-term return on investment on this," Shulkin says. "We're being driven by our beliefs . . . and we have a very vigilant chief financial officer who is nervously supportive."
Experts say disease management hinges on culling the best clinical practices, systematizing them and putting them to work wherever targeted patients need help.
"It takes 10 to 13 years from the time of a scientific discovery for it to become clinical practice," Shulkin says. "What seems like common sense takes a long time to actually filter into the consciousness of medical practitioners."
So whoever comes up with a meaningful shortcut for making new science everyday medicine--say reducing implementation time to 18 months from 10 years--will have a "huge competitive advantage," Shulkin says.
For many diseases, such as hypertension, the route to properly standardized care is pretty clear. Drug compliance alone makes a huge difference.
But involving front-line physicians early rather than dictating to them later helps increase the odds they will buy in, most disease management experts agree.
Even the best treatment protocols, based on unassailable clinical evidence, won't work wonders by themselves, though.
"Guidelines can never be a substitute for clinical judgment," says Jeff Borenstein, M.D., director of health services research at Cedars-Sinai Medical Care Foundation, Los Angeles.
Under the best of circumstances, guidelines should be consulted for the treatment of about two-thirds to three-quarters of patients. Concomitant disease or other factors limit the power of a one-size-fits-all approach, Borenstein says.
In the group practice at Cedars-Sinai, a pilot study of about 40 patients compared disease management approaches to control hypertension with traditional interventions. The results showed a dramatic improvement in patients enrolled in the disease management program--a systolic blood pressure drop averaging 24mm of Hg vs. 6 mm of Hg among the control group at six months. Significantly, Borenstein says, those improvements were achieved while saving on direct treatment costs.
The heart of the Cedars-Sinai pilot is a pharmacist-led hypertension clinic that teaches patients how to manage their disease. Coached by pharmacists, the patients learn how vital it is that they take their prescribed medication and how to manage their blood pressure. Encouraged by the results from the pilot, which was funded by a grant from Novartis, a drugmaker, Borenstein says Cedars-Sinai now is expanding the program to manage an estimated 4,400 people with hypertension among the 25,000 capitated lives contracted by its Medical Group of Beverly Hills group practice.
But giving physicians open, rather than restrictive, drug choices and plenty of feedback on patient progress has contributed to the good results as well.
A key ingredient of successful programs is lots of patient data. Access to big databases can identify which patients will benefit from disease management, such as those with severe, uncontrolled blood pressure or frequent emergency room admissions due to congestive heart failure.
In addition, good data systems can automate necessary reminders to staff and generate follow-up reports to physicians and support staff.
"Disease management can only be done with an infrastructure that can manage populations and subpopulations," says Robert Brickman, M.D., medical director for clinical effectiveness at Sentara Health System, Norfolk, Va. Everyone from case managers to doctors needs to know what's going on day to day for a particular patient, regardless of his or her location, he says. That requirement--so easy to understand yet so expensive to realize--has slowed adoption of disease management programs, Brickman says.
Despite all the chatter, most disease management initiatives to date have been limited to pilot tests or highly controlled managed-care environments. Interesting, sure, but tough for others to emulate, many physician executives say.
"It's the same people talking again and again at disease management meetings," Sentara's Brickman says.
But not because there's a lack of interest. Sentara, for instance, is trying to implement a disease management program for congestive heart failure that was highly successful in a pilot 1 1/2 years ago.
A major obstacle has been infighting between specialists and primary-care physicians.
"It takes time to build this stuff, especially when you have these mixed incentives--particularly economic incentives," Brickman says. To stay on course requires unflagging leadership, operational flexibility and never losing sight of the twin goals of patient benefit and cost savings, he says.
Only a tenth of the task of making disease management work is mastering changes in the technical practice of medicine, Shulkin says. "This whole field is about implementation."
Daunting as the challenges are, the incentives are growing stronger by the day as large physician group practices and integrated health systems vie for capitation and risk-sharing contracts. Doing so has given many physician executives the motivation to tackle the disease management challenge.
"The name of the game is demonstrating superior value," says James Couch, M.D., a disease management consultant in Coopers & Lybrand's Hartford, Conn., office. "That's what the systematic approach of disease or total management is intended to do."
Ultimately, successful disease managment programs will be a requirement rather than an afterthought, advocates say.
"It's an economic necessity for a physician organization to learn how to manage chronic illness," says Michael Abel, chairman, president and chief executive officer of Brown & Toland, a 1,250-physician IPA in San Francisco. "I wish we had done it a long time ago."
Although it already was using home-grown programs to manage a range of diseases, Brown & Toland recently contracted with HiLife, a San Francisco-based company, to help manage congestive heart failure patients, Abel says. "We couldn't wait for our cardiologists to come up with a program that was up and running," he says.
While contracting for care offers speed, it often is expensive. Still, advocates say it's worth the money if enough sick people are involved.
Eventually, trailblazers believe, disease management, whether homemade or purchased, will become a staple of group practices and integrated delivery systems.
Ironically, the growing pool of aging patients who suffer from chronic disease presents both the greatest opportunity and the greatest challenge for the disease management approach.
"Sooner or later the real problem will be integrating these programs," Borenstein says. "Unfortunately, you can't have someone in 10 or 12 programs."