Disease management programs offered by HMOs

April 1, 2006

When you try to describe a disease management (DM) program offered by an HMO, it is important to realize that there is a large amount of variation from program to program and HMO to HMO, according to industry experts.

"Most HMOs provide the big DM programs in asthma, CHF, diabetes, etc., to meet the NCQA HEDIS and accreditation requirements," says Art Taft, president of MedWorks, a DM consulting firm in Greensboro, N.C. "Others elect to support multiple sclerosis, hemophilia and HIV/AIDs often because of the illnesses' cost but also because of the patients' care needs."

Thomas Young, MD, senior vice president and corporate medical director for Connextions Health, an Orlando, Fla.-based provider of integrated healthcare services solutions, agrees. "Health plans continue to offer the classic DM programs covering chronic disease," Dr. Young says. "They also are focusing on the most ill population with enhanced case management in addition to DM programs. Plans are expanding into such areas as the management of low-back pain and mental health issues. The up-and-coming areas are the consumer-direct initiatives that have become popular as individuals take greater responsibility for their healthcare. Lifestyle issues such as weight and lack of exercise will become a major focus in the future."

Most disease management programs used by HMOs have all of these components, but can vary significantly within each category, according to Taft. "For example, one HMO identifies patients for participation in a program based on a utilization management referral," he says. "This suggests they are finding patients who have had a severe event associated with their chronic condition. These patients typically are looking for help, making the engagement process comparatively easy. But there are significant implications in the measurement process as this is a very specific sub-population of the HMO members with this condition. Other programs use analytics to identify all members of the target population.

"Another significant variant is in the intervention processes," Taft adds.

The implementation of DM programs will continue to be a major thrust of both private and publicly funded health plans, according to Dr. Young. "However, it's important to note that the most successful programs are those with communication hubs that seamlessly offer healthcare information and direction through a variety of channels, 24 hours a day," he says.

-Tracey Walker