Disease management sounds so much like plain old common sense, it seems a wonder doctors don't routinely chat with their patients on the telephone and teach them how to take better care of themselves.
Yet realistically, doing so presents a considerable challenge. While disease management programs may share some techniques--such as a commitment to patient and physician education-patient populations vary widely, which means the operation of each program can be as different as snowflakes. And accordingly, any effective disease management program will require significant resources.
Once they're in place, programs face the challenge of identifying which patients will most benefit from their help. In fact, companies such as Accordant Health Services of Greensboro, N.C., actually use algorithms to comb through claims data to identify appropriate clients.
"It's almost impossible to identify these patients without a substantial financial investment," says Steve Schelhammer, Accordant president and CEO.
Building a significant patient base to offset costs is another challenge disease management companies face.
One successful example is Cardiac Solutions of Buffalo Grove, Ill., which has seen its enrollment grow from 200 patients in 1994 to 10,000 today. The company predicts it will be profitable this year on about $40 million in revenues.
A key ingredient in its profitability is a more efficient staff-to-patient ratio, says Steve Smith, CEO of Cardiac Solutions' parent, privately held Ralin Medical. Smith declined to reveal that ratio.
The company focuses much of its efforts on patient outreach because heart conditions are made better or worse by lifestyle choices.
Its first step is to hire home-healthcare workers so there is someone on-site who can spot any need for increased patient education, such as a cabinet stocked with products high in sodium.
The visit from a home-healthcare worker is followed by telephone calls from a cardiac nurse who serves as the patient's case manager. The nurse sends a photograph of herself to establish rapport and then begins a period of intense over-the-phone education and health-status surveys, the results of which are passed to the patient's physician as necessary.
The frequency of the nurse's contact and the content of her inquiries is determined by computer-driven protocols, based on the patient's condition and company guidelines for good medical practice.
The protocol at some companies is even more hands-on. For example, Franklin Health of Upper Saddleriver, N.J., makes certain each of its enrollees has a case manager who lives in the same community as well as a centrally located clinical support team. The company works with about 500 patients, many of whom are terminally ill with AIDS, cancer or end-stage renal disease.
For most disease management companies, the objective is to keep sick patients from getting sicker; Franklin's objective must be different. About 70% of its patients are in the final stage of their lives, says William Thar, M.D., Franklin's medical director. "They're making very personal decisions about quality of life."
When patients understand their choices, Thar says, they often opt for more aggressive palliative care instead of treatments that are likely to increase discomfort, such as chemotherapy. For health plans, the return on investment in Franklin Health is about 2 to 1. And perhaps more rewarding, 70% of patients report an improved quality of life.
For Vida Healthcare of Minneapolis, physician outreach is as important as patient support. Cancer patients typically follow their physicians' lead in care, Vida officials say.
In each market it enters, the company asks a panel of recognized local cancer specialists to develop standards. Though the standards may vary little from market to market, it is important to involve local doctors in setting the guidelines, says Brian Scullion, M.D., Vida's medical director.
"Cancer, unlike diabetes or heart failure, is not about patient compliance," Scullion says. "Making sure the disease is treated correctly is a question of (educating) the physician."