Large plan shops DM boutiques for best in breed services

June 1, 2005

The marketplace increasingly relies on multi-specialty DM companies, but one organization is pursuing a contrarian approach for disease management. Cypress, Calif.-based PacifiCare Health Systems is following what Gordon K. Norman, MD, its vice president for disease management, calls a "best of breed" strategy.

Dr. Norman believes that DM companies that focus on one condition tend to do an exceptional job. "Companies that devote all their systems and specialty clinical expertise to getting the best possible results for one disease usually do a better job than a call center where generalist nurses call one patient about disease A, and the next patient about disease B," he says. "It's theoretically possible that the best firm for asthma or congestive heart failure might be one of the one-stop-shops, but as I pore over the literature and talk to my peers at other health plans, that doesn't seem to be the case." PacifiCare spends close to $40 million per year contracting for these seven disease management services for a universe of 2.5 million covered lives.

For congestive heart failure (CHF), PacifiCare uses Alere Medical Inc. of Reno, Nev. They provide CHF patients with a proprietary at-home monitoring system composed of a weight scale with a transmission box that plugs into the patient's phone line. Patients weigh themselves by standing on the scale twice a day, and answer a few yes-or-no questions about their current symptoms, prompted by messages on the transmission box. Their answers are automatically uploaded to a central hub and evaluated by a cardiac nurse.

AirLogix, of Dallas, which uses field-based respiratory therapists who make home visits, as well as nurses who offer advice over the phone, manages the respiratory program. Dr. Norman says that AirLogix has cut hospitalizations and emergency room visits due to COPD/asthma by 15% to 20%.

Many health plans offer disease management for congestive heart failure and COPD/asthma. PacifiCare is also applying DM to a number of other conditions usually not covered by a DM program. For example, it has turned to Quality Oncology, a division of Marietta, Ga.-based Matria Healthcare, to manage difficult cancer cases, using oncology nurses to work closely with patients soon after they receive a cancer diagnosis. In the emotional and mental whirlwind of a cancer diagnosis, patients often can't take in everything that's said in the doctor's office, so Quality Oncology nurses offer detailed education about cancer treatment options.

It focuses especially on preventable complications. For instance, teaching patients to aggressively hydrate themselves before chemotherapy, and giving them potent antinausea medications, can prevent dehydration that might otherwise require hospitalization.

Quality Oncology nurses focus on the cases where they can have the greatest effect, such as advanced breast and colon cancer, while in cancers with fewer complications and higher cure rates, they offer an initial orientation and are available for further consultations as needed. The program more than covers its costs, Dr. Norman says. Savings vary among the different types of cancer, up to 20%.