Three Trends Shape Disease Management in 2005

The disease management (DM) industry is constantly evolving, and this year will be no different. In 2005, DM companies must adapt to meet the shifting demands of health plans and employers, particularly in regard to increasing the integration of DM programs across the continuum of care, reaching a greater percentage of the entire population and fine-tuning methodologies to more effectively demonstrate the value of disease management to various stakeholders.

Perhaps the most significant of these trends is the managed care industry’s move toward a more fully integrated care coordination environment-one that encompasses disease management, case management, utilization review, wellness programs and behavioral health, among others. As health plans and employers look for new and creative ways to control costs, increase productivity and reduce absenteeism, this integrated approach offers a win-win scenario for employers and employees alike while laying the groundwork for the enhanced reporting of DM program value.

Naturally, providing a single point of entry will simplify the process of accessing and utilizing these services for members by bringing disparate initiatives together into one comprehensive program. It also enables actionable, member-specific recommendations to both physicians and members that will promote better health and wellness for a particular individual. By delivering all of these programs as an integrated continuum, health plans and employers will be able to increase participation rates and more directly impact member health.

Technology plays a major role in making this possible. Secure, Web-based communication facilitates the seamless exchange of information among all service providers in the continuum, allowing health management companies to improve the flow of member-related information and optimize health outcomes. For example, a disease manager should be able to send and receive messages with others in the care management process via a secure system. And if a patient is discharged following a heart attack without a beta-blocker, then the treating physician and care manager should receive a prompt, patient-specific and actionable alert. 

As a whole, the industry is also moving toward a more population-based approach to disease management, seeking to delay or even prevent the onset of chronic conditions. While previous strategies often concentrated on incident-driven utilization review and managing the most common chronic conditions, the future of health and disease management is heading toward a much more preventive approach to healthcare-one that treats hypertension and hyperlipidemia, for example, with the goal of preventing a future cardiac or cerebrovascular event.

In this example, a more preventive approach will not likely provide an immediate financial return on investment. Instead, steady progress in the population’s health and quality metrics will be seen in the short term, including better control of blood pressure, better compliance with prescribed medication and lower lipid levels. Ultimately, this approach will result in fewer heart attacks and strokes among the population during subsequent years, resulting in a solid long-term return.

By taking proactive steps to delay or eliminate the onset of costly, chronic conditions well before they begin, DM companies will be better prepared to address health conditions that are increasingly prevalent among today’s member populations, such as hypertension, hyperlipidemia, obesity and the combination of these conditions, known as metabolic syndrome. Predictive modeling will serve as a valuable tool in making these efforts possible by helping to identify those members most at risk and categorizing them accordingly. Once members are identified, DM companies can then make coordinated interventions that promote better health, including nutrition counseling, exercise plans and medication compliance. With increasing access to a higher quality of data, including lab results, self-reported medical histories and unhealthy behaviors, pharmacy and medical claims information, DM companies are well positioned to apply the increasing power of the predictive model and succeed at this new approach to DM.

The coming year will also be an opportunity for the industry to fine-tune methodologies to better demonstrate the value of DM. In the end, health plans and employers want care management programs that deliver healthy returns, but these two stakeholder groups sometimes utilize different approaches. At the aggregate, “book of business” level, health plans will continue to demand rigorous and credible population-based methodologies that convince even the most ardent skeptics. One of the ultimate goals is to pinpoint causality, meaning a direct link between the care management interventions and the outcomes.

For DM companies, the key to calculating this data lies in developing consistent, reliable methods that facilitate comparability across programs and clearly show where progress is being made. These methods should aim to accurately measure and interpret indicators so the results reflect the true clinical and financial rewards of a DM program. This data, in turn, allows health plans to better communicate with their employer customers about the benefits of DM-from improved clinical outcomes and fewer medical claims to increased self-care and enhanced productivity.

The statistically small sample sizes seen in typical employer populations can make this a challenge, but employers are showing interest in incorporating measures that are more subjective-yet still valuable-such as the prevention of adverse health events, cost-avoidance and estimates of improved absenteeism. Employers also want to see a consolidated view on the impact of all employee touch points and interventions across the care coordination continuum. Most likely, this approach will create two types of reporting initiatives, with each one geared toward the different needs of these distinct stakeholders. Those health plans and health management companies that are prepared to address both will realize a significant competitive advantage.

Jeff Odell is vice president of sales & marketing at Health Management Corporation, a leading national health and disease management company.