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April DTR Analysis:DM Programs


Disease management maintains popularity

Disease management maintains popularity

Employers need to know their employee population and continually evaluate their data-this information will assist executives in developing a business model that supports the implementation of targeted disease management programs, according to Cindy Gates, a vice president for Aon Consulting, Baltimore office.

 "The model will also assist the executive in selecting a disease management vendor capable of meeting its needs," Gates says. "Executives should negotiate prospective performance guarantees to ensure vendor accountability for service delivery and program outcomes. Executives need to ensure that the program is communicated initially and on an ongoing basis to employees and spouses/dependents eligible for program participation. Program results should be continually evaluated."

According to Gates, most of the major health plans, including Aetna, CIGNA, and UnitedHealthcare, have contracted with independent disease management firms to provide disease management programs. "Disease management programs vary by health plan, however, the core disease states generally offered include diabetes, cardiovascular disease [congestive heart failure and coronary artery disease] and asthma," she says.

 The disease management program design may vary by health plan, but most, if not all, of the health plans utilize medical and pharmacy claims data to identify members for program participation, according to Gates. "The disease management enrollment model most commonly utilized is an opt-out model," she says. "An opt-out model is one where a member identified with a chronic disease under management is considered enrolled unless they specifically request not to participate in the program. Members enrolled in the disease management program are risk-stratified into high-, moderate- and low-risk levels. The intensity of disease management interventions is aligned with an individual participant’s risk level. Interventions can include educational materials, self-directed care modules or telephonic health coaching with a clinician [registered nurse]."

Most independent disease management firms and health plans are expanding their disease management offerings to include programs such as oncology, musculoskeletal and depression, according to Gates.


Gates believes that disease management implementation may include the following steps, but will vary depending on if services are being provided by the health plan or if the employer carves the service out to an independent disease management firm:

• Negotiating the contract and performance guarantees with the disease management vendor

• Coordinating confidentiality agreements with the health plan and pharmacy vendor(s) for data exchange

• Coordinating data feeds to the disease management vendor (eligibility, medical claims. pharmacy claims)

• Reviewing program communication materials (letters, call scripts, Web site, brochures);

• Coordinating with the health plan’s care management program;

• Identifying program incentives (if any);

• Review standard program reporting; and

• Identifying and coordinating roll out of the disease management program to employees.

"In planning program implementation, whether with the health plan or independent disease management firm, it is critical that a robust communication plan be part of the program launch," Gates says. "Employers and the disease management vendor need to work together to customize an engagement approach that is best suited for the employer’s population. Barriers such as language, illiteracy, lack of telephones and/or Internet access, etc., should be considered."

Physician buy-in is also important, Gates says. "Any tools or resources that assist the physician to follow evidence-based treatment guidelines will lead to better compliance with program participants and ultimately, outcomes and productivity. For example, providing physicians with a ‘report card’ of a diabetic patient’s hemoglobin A1C and lipid testing results, with a reminder to have an annual eye exam, can be really meaningful during the patient’s next visit to the doctor."

The future of DM

"As medical benefit plan costs continue to rise, employers continue to seek new strategies to control costs," Gates says. "Most employers with a stable and aging work force consider disease management a tool that will assist in managing healthcare outcomes, medical costs and productivity. Employers are investing in the notion that creating educated healthcare consumers is a strategy that will pay off in the long term."

One challenge facing the disease management industry is to identify and develop a common methodology for calculating and reporting return on investment, Gates says. "Disease management programs are usually one component of an employer’s health management strategy. Other tools include case management, predictive modeling, high-risk outreach, and health promotion and disease prevention programs," she says.

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