Why We Can't Wait to Implement Disease Management

A minority of Americans undeniably generate the majority of health care expenses, and disease management tackles this root cause of the trends that are pounding employers. Given the size of the problem, it makes no sense for the business community to sit around and wait for detailed results of ROI analyses.

By Alison Johnson

Disease management programs are sprouting as fast as dandelions in springtime. Although hailed by the popular press and scientific journals alike, the results of ongoing research into the return on investment in disease management are far from conclusive. What should employers do? Dismiss it all as hype and await incontrovertible evidence or forge ahead? I say press on regardless, and for two compelling reasons:

• No.1: We need a new approach for chronic illness management.

• No. 2: Patients, not doctors, control their diseases (and their costs).

Why am I so determined? Because disease management programs aim at a huge financial target: In the year 2000, the U.S. spent $774 billion to treat chronic conditions. That's 70 percent of the total spent on health care. Medical costs for someone with chronic conditions are five or six times as much as those for a healthy person.

The nature of illness

In the not-too-distant past, nearly all health problems were acute. Injury and illness meant doctors and hospitals. When the emergency was over, so was health care. People knew little about the disease process and the way their bodies functioned. Responsibility for medical care rested squarely on the shoulders of doctors and nurses.

As the 20th century drew to a close, three distinct forces shifted our understanding of illness from acute to chronic, from treating health problems to preventing them. First, medical professionals and the public at large began to recognize that some acute events — like heart attacks and strokes — were manifestations of longstanding chronic disease. We could prevent some illnesses, and control the morbidity and mortality associated with others.

At the same time, we began to see the payoff of earlier breakthroughs in antibiotics, vaccines and public sanitation. People were living well into their 80s and 90s. Unfortunately, many of those lengthened life spans were blighted by debilitating disease. A healthy and active retirement became a common goal, but chronic illness was getting in the way of the healthy and active part.

Finally, a more affluent, educated and vocal generation of consumers demanded more information about their illnesses, a wider range of treatment options and greater control over their treatment regimens.

Epidemiological studies have helped us understand the effect that the choices made today have on tomorrow's illness. We feel less victimized by sudden and surprising illness, and more attuned to preventing problems. We recognize the dangers of smoking. We pass bike helmet and car seatbelt laws. We take daily medication to prevent symptoms, rather than occasional medication to treat symptoms. We seek to head off the development of illness, rather than treat it when it inevitably arrives.

Not all health care needs are chronic, of course. We still break bones and acquire infections, but now we can aim to avoid chronic health problems by treating underlying causes — high cholesterol and cigarette smoking, to name but two — in early or midlife. We see opportunities undreamed of by the generation of elderly who are retired today. Which brings us to the second reason why disease management is such a good idea.

The shift in control

In the "good old days" the doctor told you what you had to do (Take these pills. Come in for surgery. Get this lab test.), and you did it. Or did you? I'm a frequent speaker in the health care industry. When I ask an audience if anyone has ever not followed a doctor's advice, every hand shoots up. We routinely alter our medication schedules, refuse or postpone surgery, and "forget" to have lab tests done.

People see the doctor only once in a while. They live with their chronic illnesses every day. By trial and error, they figure out how to manage that disease in a way that allows them to continue to work, play and participate in life. With no more than sketchy knowledge of disease and how it affects the body, they take on the daunting task of integrating it into their lives.

Many eventually reach a comfortable equilibrium. New routines — learned with or without guidance from health care professionals — become as ingrained as brushing one's teeth. For many others, however, the daily, sometimes hourly test is, "How am I doing?" Decisions about taking medication, following a diet, testing blood pressure or glucose levels are based on how they fit into the day's activities, and how important the person believes they are to assuring well-being.

What does DM offer?

So what do disease management programs offer that make them such a good idea? A recent Milliman survey of DM companies reveals they share key features that recognize and capitalize on these two points about the chronic nature of diseases and the realization that patients are in control of disease management.

At their most basic, disease management programs aim to help people deal with their chronic illness in a way that reduces or delays its detrimental clinical and functional effects, and reduces the need for and cost of medical care. Disease management programs usually target members with chronic diseases where long term management, patient education and close monitoring for symptoms can delay or prevent complications and acute exacerbations, thus reducing the number of emergency department visits and hospitalizations.

Members are identified and enrolled, then stratified according to the severity of their disease. Nurses call members and complete thorough telephone assessments that review each individual's condition, knowledge and other factors — poor eyesight or limited mobility, for instance — that can affect a person's ability to manage a chronic illness. The nurse then builds a plan of care on strategies, including ongoing education, to improve the member's self-management skills and make it easier to comply with treatment such as physician visits, medications, lab testing and preventive activities.

How does this differ from standard approaches to controlling chronic illness? And why does it work better? "It's the caring that makes a difference" according to Bill Gold, MD, Chief Medical Officer and Vice President, Blue Cross and Blue Shield of Minnesota. "A nurse who calls you personally, and is interested in more than just your biology can be both reassuring and compelling — especially if that nurse calls when you've been newly diagnosed with a chronic condition and offers some practical advice on how to live with an illness that won't ever go away. All disease management programs provide multiple phone calls from nurses trained to assess not just your body's response to disease but your level of information about your disease, your skill and ability to manage medications and treatment, and your emotional response to your condition. When you talk to people enrolled in a DM program, you hear stories about ‘my nurse.' "

DM programs are continuous and they reach out to their enrollees. They are one of the few places in health care where all events are tracked, and tracked together. This is particularly important when someone has more than one medical condition. A person with chronic heart disease may also break a leg and be suffering from depression. Medication recommended for heart disease may be contraindicated for depression. Physical therapy to speed recovery for a broken leg may not be a good idea for a person with heart disease. Patients who are seeing different specialists for separate conditions may be on their own to sort out the advice.

DM companies describe their programs as coordinating the care for members across time, finding and providing services and resources, and supporting enrollees as they care for themselves. Some common themes are the use of multidisciplinary teams, around the clock access to health professionals by telephone, and specialized educational programs geared toward the enrollee's level of understanding and interest. The resulting sense of control the person feels encourages them to keep up with their newly developed methods for managing their health.

What about reducing the tremendous burden of health care cost? For many insurers and employers, the prospect of reducing health care expenditures is the primary reason they are attracted to disease management programs. Rising health care costs have produced pressure to bring down premium costs without sacrificing either the quality of health care or member satisfaction. True, we don't yet know if the promise of cost reduction will materialize fully, but the target is enormous and the early indications are encouraging. We can hold back until every single skeptic is satisfied, or we can get to work on the roots of health expenditure with a potent new tactic.

Alison Johnson, RN, MBA, is a health care consultant with Milliman USA who specializes in the evaluation and analysis of health care management systems and the design and implementation of health care management programs. She is the author of a recent Milliman report: "Disease Management: The Programs and the Promise." To request a free copy, contact: alison.johnson@milliman.com.

More Business & Health Articles About This Topic:

Managing the Disease (Jun. 19, 2002)

Disease Management Comes of Age, Not a Moment too Soon [(Jun. 19, 2002)

Resources:

Milliman USAhttp://www.milliman.com/health/

Alison Johnson. Why We Can't Wait to Implement Disease Management.

Business and Health

Oct. 15, 2003;21.