Disease management seen as key to cost control
Financial experts say healthcare organizations must do a better job of controlling the symptoms of chronic disease to rein in the industry’s volatile cost structure. Providers and payers generally recognize the need to team up to identify at-risk patients and use information technology to generate active correspondence, encourage positive behaviors and create interventions that reduce the number of hospital re-admissions.
“For every healthcare dollar, 87 cents is spent on physician services, inpatient and outpatient services, medications and general services,” said John Specht, vice president of sales for New York-based Vitech. “So 87 cents goes to medical management – you need to find five points in that total to get cost parity and chronic disease management goes directly to the bottom line. But it has been a struggle so far.”
The bulk of medical management costs come from patients with chronic conditions, including diabetes, congestive heart failure, chronic obstructive pulmonary disease, hypertension, asthma, osteoporosis and obesity.
“The goal is to save money and be more efficient while keeping patients healthy and getting sick patients treated so they aren’t a cash drain,” Specht said. “And contrary to what some believe, the responsibility doesn’t fall on the physician, but on the patient. They need to be incentivized to behave.”
Using Vitech’s disease management program, payers and providers can encourage plan members with chronic conditions to change their behaviors, Specht said. For example, correspondence from both the health plan and physician can get diabetic patients to come in for critical HbA1c tests, foot exams and eye tests. To offer a financial incentive, the payer can reward patients with reduced co-payments on these procedures.
“The payer sits in the middle of this equation and is the most logical conduit for data flow,” Specht said. “There should be dialogue between the payer, provider and the member – it is the medical home concept. We are the aggregation point for all interactions – we feed the care management platform.”
The doctor factor
At Dallas-based Phytel, the focus is on the physician, said Richard Hodach, MD, chief medical officer.
“We’re trying to get physicians to be happy using IT for chronic disease management,” said Hodach, a neurologist. “We want to take the experience with population health and turn it into a physician-based population health program that includes services and technology.”
Phytel has built a system that places data from multiple sources, including billing, scheduling and electronic medical records, into a patient database. It then applies evidence-based guidelines and algorithms to identify populations with chronic care needs. The system contacts patients by phone, but Phytel is also building an e-mail product and portals to be used by care managers, Hodach said.
Russell Olsen, vice president of product management for Phytel, concedes that “it is difficult for physicians to manage an entire population in a fee-for-service world because payments are based on individuals rather than groups of patients. We provide the tools for physicians to see the entire population and tell them which groups need to be contacted.”
Olsen adds that some clients are already getting measurable improvement in patient compliance with treatment regimens and scheduled appointments for HbA1c tests.
Prevea Health, a large multi-specialty healthcare organization based in Green Bay, Wis., is reporting positive results from the Phytel program. President Ashok Rai, MD, points to a diabetes study group in which 47 percent of the patients had a chronic care visit and an HbA1c test within six months of their non-adherence date, versus 16 percent in the control group. Similarly, a hypertension study group had 57 percent of patients getting a chronic care visit and systolic blood pressure reading in the specified period, compared with only 29 percent in the control group.
“Using a proactive outreach solution is an important part of Prevea Health’s vision of technology use,” Rai said. “Prevea has improved the quality of care by engaging noncompliant patients in the patient-centered treatment plans set up by its caregivers and allowing earlier interventions – especially for chronic diseases like diabetes and asthma.”
Using information technology to manage chronic diseases is the centerpiece of the industry’s new preventive care model, which the payer community is increasingly accepting and adopting, say officials from St. Louis-based Lumeris.
“Around the quality arena, clearly we focus on both improving prevention and chronic disease management,” said Debbie Zimmerman, MD, chief medical officer. Lumeris’ system is designed primarily for payers, with special attention on Medicare contractors.
“Our company takes its history from the Medicare Advantage health plan and is built on the collaborative payer model, partnering with physician groups,” Zimmerman said. “The premise is taking those teachings and providing software that health plans and physician groups can use to help improve cost and quality of care. It started with Medicare Advantage, but it is also for commercial Medicaid and other types of payers to apply to any population.”
The Centers for Medicare and Medicaid Services ties dollars around its Star Rating program and is expanding to a Five Star format in 2012. Under the program, bonus payments are tied to health plan performance for clinical and operations metrics, with chronic disease prevention and management the ultimate goal.
“The tool Lumeris provides is designed to be more proactive so that tests are completed before chronic conditions become more complicated,” said John Khoury, Lumeris’ director of clinical decision support.
Andrew Shea, director of marketing, adds that the tools in the Lumeris platform aren’t just for health plans – they can also be used by large health systems and accountable care organizations.