Disease management as we now define it may be on its last legs, though no one knows it yet. The Disease Management Purchasing Consortium has noticed that the savings in all but a few diseases doesn't offset the costs, and nowhere does it generate the level of return on investment (ROI) that some people think they are getting.
The State Children's Health Insurance Program (SCHIP) will expire September 30, 2007, unless Congress approves legislation reauthorizing this popular program offering healthcare services for children and some adults. The deadline puts this issue at the top of the Congressional agenda as an opportunity for Democratic leaders to increase public access to care. Efforts to expand coverage for children and secure the Medicare program are important to the managed care community because the legislators are eyeing "overpayments" to Medicare Advantage plans as a possible source for some $50 billion to fund SCHIP and other healthcare programs.
Care management has become an increasing challenge for America's healthcare system. Given the open-access approach and flexibility in allowing consumer choice, how do preferred provider organizations (PPOs) approach the issue of coordinating care for chronically ill beneficiaries? In 2005, more than 133 million Americans had one or more chronic conditions. Their care accounted for 83% of all healthcare spending. People with chronic conditions tend to have multiple illnesses and multiple providers, making care coordination that much more critical and challenging for all stakeholders. Some key approaches used to coordinate services in PPO models of healthcare include utilization management (UM), case management (CM) and disease management (DM). In addition, PPOs are adopting strategies to identify high-risk patients early and to prevent the onset of chronic conditions.
National reports—While national expenditures on bariatric surgery have increased, the average cost per patient has declined, say industry experts.
DIABETES, ASTHMA cardiovascular disorders, high-risk pregnancy and chronic obstructive pulmonary disease (COPD), will continue to account for anywhere between 55% and 70% of medical costs, according to industry experts. For these disease states, executives are taking a look at more creative DM programs, but they also are seeing emerging diseases on the horizon.
Disease management programs aimed at enhancing quality of life for older adults with multiple chronic illnesses are blossoming and are expected to experience future growth.
Traditionally, "behavioral health" refers to mental-health and substance-abuse treatment through psychosocial and/or pharmacy care, says Gregory Bayer, PhD.
Legislation encouraging more equitable coverage of mental illness is moving forward in Congress following important modification of previous requirements. The Senate Health, Education, Labor and Pensions (HELP) Committee recently approved a bill that requires health plans to offer similar benefits for mental and physical illness in terms of deductibles, copayments and treatment limitations. But the new measure no longer mandates that group health plans cover mental illness.
Fundamental Enablers: Optima Health President Michael M. Dudley says not-for-profits compete on historical strengths of quality, local engagement
As the managed care industry continues to consolidate, not-for-profit and provider-sponsored plans haven't lost their niche in the marketplace. They compete on demonstrated quality and the added value of community accessibility, which would, on the surface, seem to be exactly what politicians and healthcare advocates are begging for.
Last year acknowledged the 25th year since AIDS was first recognized, and to coincide with that anniversary, the U.S. Centers for Disease Control and Prevention (CDC) revised its recommendations for HIV testing for adults, adolescents and pregnant women in healthcare settings. The new guidelines remove the onus of determining who is at high risk for HIV infection and makes testing a routine part of medical care for all patients between ages 13 and 64 years.