Introduction
The need to offer a more comprehensive form of healthcare to the population has been motivated by several factors, these include; changing demographics that have seen the increase in the proportion of older people in the population, increased costs of healthcare services, increased proportion of uninsured and underinsured people, increased cultural, ethnic and racial diversity, increase in the prevalence of preventable chronic diseases such as obesity and type II diabetes mellitus and the prevalent outlook of the country’s and world economy. The healthcare services provision sector has had to face the double challenge of providing effective medical care; and doing so within the feasible economic limits. The efforts to attain this have not been entirely successful; resulting in a significant proportion of the population not receiving the optimum care due.
To mitigate this, several interventions have been put in place; and with varied successes. Indeed, healthcare provision has become a major point of contention even on a national stage; and has continued to fill the plate of the federal and respective state governments. One of the steps that have been developed to improve the situation of healthcare services delivery is disease management programs (Norman, 2008; Goetzel, et al, 2005).
Disease Management
This has been one of the key aspects that have been developed with the aim of reducing the costs of healthcare services and improving the quality of the services seen as better outcomes to medical interventions. Such requires the creation of a system whereby there is a continuum of care between various levels of care as facilitated by development of a coordinated healthcare system with effective communication between the various levels; and the incorporation of aspects of self-care, not only to reduce the costs, but also to prevent the occurrence of acute-care episodes and adverse outcomes to disease and/or medical intervention (Esposito et al, 2009; Norman, 2008).
The development of this concept was prompted mainly by the increased prevalence of chronic diseases such as diabetes mellitus, AIDS, heart disease and chronic renal disease in the population (Bott et al, 2009). The aspects of these diseases that spurred action were the costs involved in the long term management in a large population; and the tendency of the diseases to result in adverse outcomes after the development of co-morbidities. As such, there has been a need for the intensive management of the diseases from their very onset both to save costs and to reduce the probability of future complications.
Disease management programs have various functions; most important of these is supporting the relationship between the physician and patient; and therefore facilitating the proper implementation of the plan of care. The program also prevents the development of complications or co-morbidities; and adverse outcomes of disease and/or medical interventions. Additionally, programs have components that evaluate costs and benefits of the program; thus allowing for regular adjustments so as to maintain relevance and purpose.
Players in the Disease management sector
Many vendors have entered into the market as the concept continues to develop; some of these include Accordant, Alere, Caremark, Evercare, LifeMasters, McKesson Health Solutions among many others. These vendors mainly base their participation on the generation of revenue. This accounted for approximately $600 million of the revenue generated in 2003 by the healthcare industry in the United States; and was an improvement from $300 million just one year before; and $120 million in 2001. This number is expected to increase to $2.8 billion by the year 2010 if the current growth trend is anything to go by (HIRC, 2008).
Indeed, disease management is one of the fastest growing trends in the healthcare services industries; and is an indication of a paradigm shift in the manner which healthcare services are dispensed to the population in the country (Norman, 2008; Kovner & Neuhauser, 2004). This has continued to attract many players; with the Disease Management Purchasing Consortium and Advisory Council listing upto 60 independent companies dealing with disease management in their DM Vendor Profiles catalogue. Additionally, many health plans and pharmaceutical companies have divisions within their structures that deal with disease management.
Analysis of Disease-Specific Management Programs
As mentioned before, the provision of healthcare services is a major point of contention in the American society; with debate ranging from aspects such as social welfare and medical outcome; to economic impactions of disease and its management. As such, there has been a growing need to analyze the effectiveness of disease management programs in mitigating the shortcoming of healthcare provision in the country. This has been driven by the need to allocate scarce resources to unlimited needs. Therefore, by analyzing whether DM programs are delivering all they are touted to do is paramount to the evolution of the healthcare industry to enable it to deliver to the fast changing and increasingly challenging population.
It is important to differentiate between efficacy and effectiveness while analyzing a disease-specific program; a program may demonstrate superior clinical outcomes during clinical trial but fail to achieve the same after application in the day-to-day delivery of services. As such, it is important, during clinical trials, to factor in issues that may affect the efficiency of the program in the field (Bott et al, 2009).
There are two variables that are of great importance during the analysis of disease management. One is the cost of healthcare services; and the other is the quality of the services as depicted by the outcomes of the disease. Typically, commercial disease management vendors tout their products as being patient-centered, high-quality and low in costs. When analyzing a program, it is therefore important to consider these two variables.
The analysis process
The main basis of disease management is the realization that some diseases cannot be cured and requires intensive and long term management to prevent the development of complications and/or co-morbidities. Therefore, the only solution to such situations is to ease the course of the disease as much as possible. Indeed, while the health benefits of disease management may be measurable in the short term, the economic benefits can only be measured on the long term; and care has to be taken to factor in the reduction in the cost of disease in the population above the costs of healthcare services. Such would require the analysis of a large volume and range of data spanning a period of 10 to 20 years; and sourced from a wide variety of databases including demographic, social and economic.
Clinical guidelines and web-based assessment are some of the available research tools. Many other devices, systems and protocols are also available for use. The choice of the tool depends on the type of study, the type of program being studied and the expected results; the availability of resources to carry out the study; and the availability of well organized and detailed databases. Some of the equipment and resources that may be necessary to carry out a study include mailing systems, interactive or non-interactive web-based applications, monitoring devices, or telephonic systems; that availability of these resources plays a key role in determining the method of study chosen.
To have a detailed picture of the situation in the field, a wide range of players should be involved in giving information about the two study parameters; such would include actuaries, physicians, medical economists, nurses, nurse practitioners, nutritionists, physical therapists, statistical experts, epidemiologists, and human resources professionals. Such would serve to create a three dimensional picture of the situation; and would allow the exploration of aspects of population health that are outside the immediate scope of medical practice.
As with any other scientific study, the risk of bias is always lurking. In the case of the analysis of the effectiveness of disease management programs, self-selection bias is more likely to occur in cases where enrollment into the program is voluntary. This may arise from the fact that such enrollees will already be highly motivated to have a healthy lifestyle. Consequently, the study of such a group in isolation would not result in an accurate depiction of the situation in the general population; indeed, studies have demonstrated that such enrollees have significant differences in terms of demographic parameters, utilization of health services and expenditure in comparison to the non-enrolled population (Buntin et al, 2009). To reduce this bias, randomized controlled trials would result in more accurate outcomes as opposed to observational studies; as the former would overcome the baseline differences in the characteristics of the subject groups (Linden et al, 2006).
Analysis
Effectiveness of a disease specific management program can be done on several planes and angles so as to derive data regarding its effects on costs and patient outcomes. The method used to analyze each of the planes depends on the resources available, the type of data available (and required) and the type of study group/subject in the plane. As such, a study carried out among medical practitioners would require face-to-face and/or telephone interview; and/or questionnaires. Some of the study planes include physician attitude toward DM; program components; vendor evaluation; economic impact on the organization; and advantages and disadvantages of outsourcing or using an in-house DM program.
Disease management program components
For a disease management program to be properly constituted there are various components that are necessary; and their absence/presence can be used to evaluate the effectiveness of the program. For starters, the program has to be run in accordance to an evidence-based practice guideline that will determine the best course of action during the management of each of the enrolled patient. Additionally, the program should be modeled to incorporate all the relevant institutions and medical professionals; so as to offer a comprehensive service to the enrollee.
As mentioned, before, disease management has an important aspect of self-care; for this to be successful, a program has to have a component of patient education. The subjects may range from primary prevention, self-medication; to lifestyle modification. The program should also have a system for the flow of information across the various levels of care; this should be linked to a method of monitoring the process and measuring the outcomes of the programs both in terms of health benefits and cost reduction.
Finally, as mentioned before, disease management is aimed at improving the health at the level of the population. As such, it is important to have a mechanism to identify, analyze and classify the population. Such would allow for accurate targeting of interventions aimed at manipulating the health outcomes at the level of the population; and its effects on the social and economic dynamics on a national level.
At the core of the program, there should be a smooth interaction between well trained efficient and diverse personnel; a detailed and efficient information management system; and evidence-based clinical practice guidelines. Such would allow the program to handle the enrollee with maximum accuracy and efficiency; and would augment to the achievement of the dual goals of improving the health outcomes and reducing the costs of managing the specific disease.
Physicians’ attitudes towards disease management
A proper assessment of the attitudes that requires face-to-face and/or telephone interviews and/or filling of questionnaires would be the proper mode of evaluation. The attitude of the physicians is very important as they offer a major component of the healthcare delivery system; and their contributions are mandatory for the system to function. Indeed, if the physicians view the program in a negative light, this has the potential of crippling the effectiveness of the program.
Issues arising from the program that may cause hostile sentiments among physicians include an increased workload without a corresponding increase in income; or with a reduced income; and fragmentation of the healthcare system due to the management of co-morbidities in an individual in separate programs.
Other factors include the loss of clinical skill by physicians due to reduced participation in the management of chronic diseases; conflicts between economic and health aspects of the population with the subsequent negligence of certain disease and/or population segments and the lack of peer-reviewed evidence of the benefits of disease management programs to support implementation (Mattke et al, 2004).
Many of these concerns are genuine and shared by other parties, while many other are fueled by the fear (on the part of the physician) on loosing income and/or relevance in the management of chronic diseases. Indeed, while some of the fears may be allayed, others require the physicians to adapt to the changing landscape.
Economic impact on the organization
The general aim of disease management programs is to reduce the costs of healthcare service. This may however mean the reduction of the revenues generated by an organization either through the diversion of funds intended for DM to out-sourced vendor or the reduction of the total money spent in in-house programs.
Indeed, as the cost incurred to the hospital/organization in delivering the services reduces, the pressure usually mounts to reduce compensations paid to (them). On the flip side, while the programs may have increased efficiency, the workload on the organizational personnel may very-well increase. Consequently, the organization gets less money for more work done.
Outsourced vendors versus in-house disease management programs
The choice between outsourcing disease management services to corporate vendors and developing in-house programs is often tricky. One advantage of outsourcing is the instant solutions it offers; most of the vendors have ready-to-go structure within their system to handle the new workload without any interruption of the care continuum. On the contrary, it would take an in-house program precious time and resource to attain similar operating capacity. While most vendors start with one disease, most usually develop structures and capacity to handle multiple diseases; this prevents excessive fragmentation of the care continuum.
On the other hand, outsourcing will not only undermine the patient-physician relationship due to third party intrusion, it will also prevent physicians from handling chronic diseases therefore resulting in the loss of clinical skills (Mattke et al, 2007). In-house programs have the advantage of helping physicians handle these cases better. Additionally, the physicians will be able to exploit funds dedicated to disease management rather than have corporate vendors claim the entire stake.
Vendor analysis
As mentioned before, there are over 60 independent companies acting as vendors; in addition to numerous in-house disease management programs. These vendors are in the industry primarily as commercial ventures; and usually enter into contract with at-risk health plans and with self-insured employers. Concerns have been raised regarding the inaccurate claims by vendors of the benefits of DM programs; and the conflicts between commercial and population-health goals of the programs resulting in negligence of some diseases and/or populations (Bott et al, 2009; Esposito et al, 2008; Mattke et al, 2007).
In the analysis of a vendor, the presence and quality of the components of a DM program have to be ascertained. Additionally, the vendor has to demonstrate a system able to allow a smooth transition between the hospital and the DM program. Finally, issues of capacity are also important; for example, the capacity and structures to handle more than one chronic disease.
Conclusion
Since DM programs are aimed at primarily improving the delivery of healthcare services on a population level, it is important to have regular and well structured studies of the program to ensure that the two major goals are attained; that is, improvement of the services rendered and reduction in the overall costs.
References
Bott DM, Kapp MC, Johnson LB, Magno LM. (2009): Disease management for chronically ill beneficiaries in traditional Medicare. Health Affairs; 28(1):86-98.
Buntin MB, et al (2009): Who gets disease management? Journal of General Internal Medicine 2009.
Esposito D, et al (2008). Impacts of a disease management program for dually eligible beneficiaries. Health Care Financing Review 2008; 30:27-45.
Goetzel RZ, et al (2005). Return on investment in disease management: a review. Health Care Financing Review: 26(4):1-19.
Kovner, A. R. and Neuhauser, D. (2004): Health services management: Readings, cases, and commentary (8th ed.). Chicago: Health Administration Press.
Leading disease management organizations. Santa Cruz, CA: Health Industries Research Companies, 2008. Web.
Linden A, et al (2006): Strengthening the case for disease management effectiveness: un-hiding the hidden bias. Journal of Evaluation in Clinical Practice 2006; 12(2):140-7.
Mattke S, et al (2007). Evidence for the effect of disease management: is $1 billion a year a good investment? American Journal of Managed Care: 13(12):670-6.
Norman GK. (2008): All things considered, the answer is a resounding yes. American Journal of Managed Care; 14:e2-e4.