Shortly after he was hospitalized for an asthma attack last year, 3-year-old Tommy Van Gemert made a new friend in Roary the Lion, a stuffed toy whose asthma keeps him from roaring. Tommy received Roary in the mail, along with asthma equipment he needs and instructions on how to best manage his condition.
The asthma kit and lion toy did not come from a favorite aunt or a small-town doctor; it came from Cigna HealthCare, Tommy's insurance company.
"I thought the kit was wonderful," says Wendy Van Gemert, Tommy's mother and a resident of Mullica Hill, N.J.
The asthma-care package may seem like a marketing gimmick, but it's much more than that. For patients, such efforts represent an opportunity to participate more actively in managing their care. For Cigna, Roary the Lion is part of a program designed to keep chronic patients out of the hospital.
Mayo Clinic in Rochester, Minn., wants the same things but has taken a different approach. Together with 40% of the providers in Minnesota, Mayo participates in the state's Institute for Clinical Systems Improvement, through which clinicians exchange information on how best to manage care for patients with chronic diseases. Partly as a result of that, at Mayo only 10 of every 1,000 asthma patients visited the emergency room last year, compared with an industry benchmark of 90 annual ER visits per 1,000 asthma patients.
Both of these approaches to managing patient care can be classified under the nebulous and sometimes unpopular term "disease management." Although slow to catch on, especially among physicians, interest in the concept is accelerating as providers and payers alike see the benefits of using clinical guidelines and communication-even outside the hospital or office setting-to prevent lapses in care.
"If you can drop the hospitalization rate, that's substantial, quantum-level savings," says Robert Nesse, a Mayo family practice physician and vice chairman of the clinic's Rochester Board of Governors.
The management of chronic patients is a growth industry; more and more companies are being formed to help insurers and providers meet this need. Last year, disease-management companies accounted for some $600 million in revenue, up from $300 million in 1999 and $150 million in 1998, according to Boston Consulting Group, a multi-industry advisory firm.
The rising interest in disease management comes at a time when a backlash against managed care has forced insurers to offer more benefits at a higher cost to employers and consumers. Meanwhile, healthcare faces an increasing need to contain costs. Actively managing patients' chronic conditions-quite often the most expensive for hospitals and doctors to treat-is one way to do that.
"We're really moving into the second life of disease management," says Warren Todd, executive director of the Washington-based Disease Management Association of America (DMAA). "More contracts are being signed between health plans and disease-management companies than ever."
In search of a definition
Disease management can be as simple as a pharmaceutical pamphlet describing how best to use a medication or as complex as nurse case managers developing individualized care plans and regularly contacting patients to ensure compliance with the plans.
Disease management, Nesse says, is "a process in search of a definition."
As its role and reach continue to evolve, however, disease management is making a clinical and economic case for itself. It takes nothing more complicated than a telephone, proponents say, to make sure a diabetic is watching weight and glucose levels. Doing so keeps patients healthier and saves the system significant money.
"Congestive heart failure admissions are not profitable for hospitals," says Christobel Selecky, chief executive officer of LifeMasters, an Orange County, Calif., company that manages more than 50,000 patients with chronic conditions. "The DRG payment generally does not cover the cost of these patients. These aren't the ones you want in your hospital."
In addition to facilitating communication with patients, disease management allows caregivers to share clinical guidelines and best practice data to promote the best care for a given condition. Outcomes improve, the thinking goes, when caregivers have available the optimal treatment information for each type of chronic patient.
LifeMasters and similar companies use a variety of methods-including telephone, Internet and in-person visits-to keep high-risk, high-cost patients out of the hospital. These companies, in conjunction with provider organizations and health plans, collect data from and send reminders to patients who need constant monitoring.
They also provide information systems that help caregivers develop care plans and aggregate data for clinical improvement initiatives. So far, 25 of the 37 hospitals in Maine are using such tools to run the state's ME CARES program.
High hopes in Maine
ME CARES is a community outreach and disease-management effort with the goal of enabling hospitals to better manage congestive heart failure and cardiovascular disease. It is also one of 15 sites across the U.S. selected by the Centers for Medicare and Medicaid Services (formerly HCFA) for participation in a disease-management demonstration program scheduled to start later this year.
As the Maine hospitals wait for the White House Office of Management and Budget to approve a waiver necessary to secure funds from CMS, they are optimistic based on early results about how well the program is going to work.
"We're just finishing up our first year so we can't really say we've saved a million dollars yet, but the projections are that we will," says John LeCasse, president of Medicare Care Development, a not-for-profit organization that works to improve the quality of healthcare in Maine. "Our projection is a 35% reduction in hospital costs."
All of the 25 hospitals participating in the ME CARES program use a common clinical information system provided by Pfizer Health Solutions, a subsidiary of pharmaceutical giant Pfizer, to develop detailed care plans and keep tabs on patients once they're no longer in the hospital.
So far, more than 700 patients with congestive heart failure are enrolled. When a patients leave the hospital, they meet with a nurse to go over their care plan and have a computer record created. After that, nurses contact the patients on a regular basis to follow up.
Over 31/2 months, the congestive heart failure patients in Maine dramatically improved their average physical health scores, a measure of several factors including weight, diet and exercise.
"By maintaining patients' clinical behavior, you're going to keep their condition under control and not have as many inpatient admissions," says Lisa Casasanta, a senior project manager at Pfizer Health. That task, she says, would be "incredibly difficult" without the information system to track the progress of each patient against care plans and outcomes.
Use of the software has led to a 30% reduction in hospital admissions for some Pfizer Health customers, says Nancy Steele, a company vice president.
If the government approves the Maine waiver, the state's hospitals would receive $535,000 over four years to demonstrate the financial viability of a Medicare-sponsored regional disease-management initiative.
For those that have been at it a little longer, disease management is proving to be a worthwhile clinical and financial endeavor. Cigna, one of the nation's largest health plans with 14.3 million members, has been managing patients with chronic conditions on a national basis since 1995.
Hartford, Conn.-based Cigna claims that its disease-management program achieves the hoped-for result: increasing clinical quality and member satisfaction and cutting costs.
Providers may share those goals with their counterparts on the payer side, but most disease-management programs are run by health plans. That could be because economics favors groups that manage risk-health insurers and large provider organizations.
Doing the right thing
Regardless of which organization runs the program, everyone benefits from using clinical guidelines to deliver high-quality care, disease-management supporters say.
"Doing the right thing and avoiding doing things that are ineffective or not doing things that are absolutely necessary will result in a net decrease in medical costs," says Victor Villagra, M.D., Cigna's vice president for quality and strategic medical affairs and president of the DMAA.
Cigna has seen a 26.2% decrease in admissions per 1,000 diabetes patients enrolled in its Well Aware diabetes program. The health plan estimates a 14.7% reduction in costs associated with treating those patients. Cigna also manages patients with back pain and asthma, and cardiac patients are slated to join a similar program.
Maintaining contact with patients and keeping them in tune with their care plans, according to Villagra, enables Cigna not only to improve care and keep people out of the hospital but also make the doctor's job easier.
"By making it more participatory, we move away from a paternalistic approach to care," Villagra says. "The patient/physician interaction becomes much more of a shared responsibility."
Health plans have come to understand that "programs focused on improving outcomes (and) making the population healthier have a real potential for saving significant amounts of money, because healthier people cost less money to the healthcare system," says Robert Stone, executive vice president of American Healthways, a Nashville-based disease-management company that helps Cigna administer its diabetes program.
Costs for Medicare beneficiaries enrolled in American Healthways' diabetes-management program declined 17.1%, or $114 per diabetes member per month, in a one-year period, according to company research. That means savings of $1.36 million per 1,000 Medicare members with diabetes. Fewer hospitalizations have resulted in bigger savings. For diabetes patients who continuously participated in American Healthways' program over one year, hospitalization costs fell 23.7%, or $67.91 per member per month.
Not all disease-management efforts are so effective, Stone says, because many do not appropriately involve the physician. "Any program that `disintermediates' the physician's relationship with the patient is going to create a problem."
"Only recently have hospitals begun to understand the economic burden of taking care of (chronic) patients," says David Kibbe, M.D., chairman of Canopy Systems, a Chapel Hill, N.C.-based provider of a Web-based disease management program. "They're starting to understand that they have to think about what happens to these patients after they leave the hospital."
One way to standardize ongoing communication with patients is to use the Internet, and many disease-management companies are doing that. Using Web-based applications, patients can log on to send data to case managers who can catch problems before they result in hospitalization.
But concerns about security and privacy-especially in light of new federal regulations requiring the secure exchange of sensitive patient data-may put off the day when the online approach becomes more practical.
"HHS did not intend to kill disease management" when it issued the final privacy regulations, which are authorized under the Health Insurance Portability and Accountability Act of 1996, Todd says.