Tuesday, December 11, 2007

More Discrediting of "Disease Management" Programs

There is growing evidence that so-called "disease management" programs do not prove their worth, at least in terms of saving money on healthcare spending. According to a study issued by the RAND Corporation, such programs appear to improve the quality of health care, but there is little evidence that such efforts actually save money. The RAND study is not the first to raise this question. A 2004 report from the Congressional Budget Office (CBO) raised its own concerns, saying that there was "insufficient evidence" that disease management programs can reduce overall health spending, or generate savings for federal health programs such as Medicare, which prompted a bigger investigation into the issue. Diabetes is perhaps the condition most often targeted by such disease management programs because it is relatively easy to do a glycosated hemoglobin (better known as the hemoglobin A1C) blood test to show reported progress (or lack thereof), while other chronic conditions are more difficult to quantify results.

A 2004 article published in The Wall Street Journal cited statistics from Mercer Human Resources Consulting which indicated a growing percentage of employer-sponsored health plans were offering disease-management programs. A more recent article indicates that health insurance plans and employers nationally in 2005 spent about $1.2 billion on disease management programs, with 96% of the top 150 U.S. health insurance companies offering some form of "disease management" program, apparently with little to show for that investment. Most health plans outsource such work to more than 100 companies that have crowded into the market. Typically, chronically ill patients are monitored over the phone via nurse call centers, which work with information provided by labs, doctors and pharmacies. But these plans sometimes use automated response systems to check on patients, rather than actual people. The evidence also suggests that disease-management programs have been expanded to include depression, cancer, kidney disease, obesity and lower-back pain. But money talks, and the dollars being spent on these programs have yet to prove their worth.

The next time your healthcare provider wants to enroll you in a "disease management" plan to help you manage your diabetes, you may want to decline it, citing the statistics provided in these two articles. The bigger question is why we continue to spend our scarce healthcare dollars on these plans, which based on personal experience with them, annoy patients yet provide little in the way of assistance in actually managing chronic illnesses? The evidence is mounting that they do little to help improve healthcare, or save money.

I am including two articles which raise questions on these programs, the first one being very recent, the latter dating back to October 2004 but surprisingly, most of which is still very relevant, even today.

Disease Management Programs
December 11, 2007

Disease management programs that help guide the care of patients with chronic health problems appear to improve the quality of health care, but there is little evidence that such efforts actually save money, according to a study issued by the RAND Corporation.

The RAND Health study reviewed all past research on disease management programs, which seek to help patients with conditions like diabetes and congestive heart failure by offering a system of coordinated healthcare interventions. These interventions can range from pre-recorded telephone reminders to home visits by medical professionals.

Researchers selected 29 evaluations, systemic reviews and meta-analyses to focus on, covering 317 unique studies. That review found consistent evidence that these programs can improve health care quality, improve disease control, and, in the case of patients with congestive heart failure, reduce hospital admission rates. But patients with depression who were enrolled in disease management programs were more likely to use outpatient care and prescription drugs, increasing costs. There also is little evidence about whether these programs improve health outcomes over the long term.

"Disease management is viewed as the silver bullet that can fix two problems of the health care system -inadequate quality and high costs," said Soeren Mattke, lead author of the report and a senior natural scientist at RAND, a nonprofit research organization. "Unfortunately, while there is evidence that disease management programs can indeed improve the quality of care, there is no conclusive evidence that they can actually save money."

Health insurance plans and employers nationally in 2005 spent about $1.2 billion on disease management programs, with 96% of the top 150 U.S. health insurance companies offering some form of disease management service. The topic also has become a key point in the national health care reform debate, as policymakers search for a way to improve health care quality and access, while controlling costs at the same time.

The RAND study analyzed research on various disease management programs and their effect on six chronic conditions: congestive heart failure, coronary artery disease, diabetes, asthma, depression and chronic obstructive pulmonary disease. With the exception of asthma and chronic obstructive pulmonary disease, which showed inconclusive results, researchers found consistent evidence that disease management programs did improve the quality of health care. There also was consistent evidence that patients with congestive heart failure and depression reported improved quality of life.

But evidence of cost-savings was inconclusive for most of the conditions, indicating that further research is needed. It is plausible that disease management programs reduce costs for congestive heart failure patients because many programs reduce hospital admissions for these patients, Mattke said. In contrast, research has shown that patients with depression are commonly under-treated, so a disease management program that actively screens for depression and encourages patients to get treatment will increase costs.

Most of the studies Mattke and his colleagues reviewed followed patients only for about a year, which is not long enough to assess long-term health outcomes. For example, a disease management program may improve a patient's cholesterol levels in the short term, but it can take years to determine whether those interventions -- assuming they were sustained for a long period -- prevent heart attacks and costly hospitalizations years into the future.

"People take for granted that these programs work and save money, because the concept is very plausible," Mattke said. "But many things in medicine sound plausible until you do the research and find that promises don't hold true."

Health insurance plans, employers and policymakers also will have to evaluate whether the benefits of disease management programs are worthwhile, despite the lack of evidence for cost-savings, Mattke said.

Another factor is that "disease management" itself is not well-defined, Mattke said. The types of interventions can vary from congestive heart failure specialists at a local hospital hiring a nurse to educate patients about preventive care to large-scale programs reaching thousands of patients. Some programs may be better than others, but there has not been enough research to properly assess which ones are the most effective or what characteristics are associated with more successful programs.

"Just because one type of intervention can benefit one disease, that doesn't mean it will work the same way for another disease," Mattke said. "Most of the evidence for disease management comes from small provider-centered programs at academic medical centers or multi-specialty groups."

The study, "Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?" will appear in the December issue of The American Journal of Managed Care. The other authors of the study are Michael Seid of Cincinnati Children's Hospital, and Sai Ma of Johns Hopkins Bloomberg School of Public Health.

RAND Health, a division of RAND, is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care quality, costs and delivery, among other topics.

The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world.

Source: Lisa Sodders, RAND Corporation. Article adapted by Medical News Today from original press release.

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The Informed Patient: "Does Disease Management Pay Off?"

By Laura Landro, The Wall Street Journal
October 20, 2004

A growing number of disease-management programs offer to monitor patients with chronic conditions and help avoid dangerous complications that might lead to catastrophic and expensive illnesses tomorrow. But the long-term cost effectiveness of such programs has been hard to measure -- and that is raising some thorny issues in the debate over how to contain health-care costs.

By most estimates, people with chronic diseases account for more than two-thirds of the nation's $1.6 trillion medical bill, a figure that is expected to grow as baby boomers age. The aim of disease management, whether through the family doctor or a health-plan service, is to educate patients about their disease and help them manage its symptoms, such as controlling blood sugar in diabetics to stave off blindness, kidney failure and amputations.

The percentage of employer-sponsored health plans offering disease-management programs grew to 58% last year from 41% the year before, according to Mercer Human Resources Consulting. A number of health plans outsource such work to more than 100 companies that have crowded into the market. Typically, chronically ill patients are monitored over the phone via nurse call centers, which work with information provided by labs, doctors and pharmacies. Disease-management programs are now expanding to include depression, cancer, kidney disease, obesity and lower-back pain.

There is plenty of evidence to show that taking better care of chronically ill patients can improve the quality of life, slow the progression of disease and reduce hospitalizations. "We've made real progress in keeping people healthier who have chronic illnesses," says Edward Wagner, director of the MacColl Institute for Healthcare Innovation at the nonprofit Group Health Cooperative's Center for Health Studies in Seattle. "But we still don't know definitively what the economic impacts of disease management are."

While he supports doctors' efforts to help their own patients manage disease, Dr. Wagner expresses skepticism about outsourced disease-management programs, which sometimes use automated response systems to check on patients. Hands-on efforts "should not be mixed up with the more expensive and more visible activities of disease-management vendors, where evidence has been very flimsy," Dr. Wagner says.

Last week, the Congressional Budget Office raised its own concerns, saying in a new report that there is insufficient evidence that disease management can reduce overall health spending, or generate savings for federal health programs such as Medicare, which covers the oldest and sickest patients. While the CBO report says disease-management programs can be worthwhile even if they don't reduce costs, it notes that there haven't yet been enough broad population-based studies or clinical trials to demonstrate that disease-management programs cut costs -- and there is a chance disease-management programs could actually raise costs by increasing the amount of medical care patients use.

The report touches on delicate subjects. For example, staving off health problems of chronically ill patients can improve and extend life, but the longer a patient lives, the report notes, the more likely he or she is to die later of more serious illnesses, such as cancer, which cost more to treat.

Medicare is about to launch an ambitious pilot program to test disease-management programs. That plan is expected to include about 10 to 12 different sites around the country, covering 20,000 or more patients each. The CBO says it will monitor that study, using it to help weigh the costs versus benefits.

Christobel Selecky, president of the
Disease Management Association of America
, a trade group, and executive chairman of LifeMasters, a leading disease-management company, says that the congressional report does not reflect the most recent studies showing the clear cost benefits of disease management. Today, studies will be presented at the group's annual meeting in Orlando that show cost savings from 10 different diabetes-management programs and 11 asthma programs.

Cigna Corp., the big insurer, also says disease-management is cost-effective. A study in the most recent edition of Health Affairs of diabetic patients in Cigna health-care plans showed that the quality of care was higher and the overall cost of care significantly lower in plans with disease-management programs than in those without such programs. Indeed, Cigna saved more than it spent.

"These programs have a profound impact on the quality of care and costs on a short- to intermediate-term basis," says Allen Woolf, Cigna's national medical director. While it may not be clear if over the duration of a patient's life the programs decrease costs, for commercial insurers who may cover any given employee for five to seven years, "in those frames our data and the medical literature provide very strong support for offering these programs."

Robert Stone, executive vice president of disease-management firm American Healthways, which runs Cigna's programs, says that in addition to reducing costs for sicker patients, "if you get the newly diagnosed and healthier patients in the programs and help them stay in relatively good health, you can reduce later costs." Large employers are renewing their disease-management contracts because they see clear savings, he adds.

David Cutler, a professor of economics at Harvard University, says it's important to factor in benefits the CBO report didn't consider, such as increased productivity and fewer absences from work. But even if disease management is at best a break-even proposition, "from the societal level, comprehensive disease-management programs are clearly worth the investment," says Mr. Cutler. "What we care about is being healthy and having a higher quality of life, and if we can get there at no net long-term cost, that is undoubtedly a good thing."

E-mail Informedpatient@wsj.com

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Jenny said...

The Diabetes Management program my insurer runs tells people with diabetes to eat high carb low fat diets and occasionally send them newsletters warning them about the dangers of cutting carbs and the importance of eliminating fat.

When I was in the hospital lately (long, stupid story. I'm fine), the "carb controlled diabetes diet" I was put on gave me pancakes for breakfast, pasta for lunch, and sugary fruit at every meal, but did not let me have coffee. The eggs were powdered and the cheese was carb-added low fat. And the nurse's glucose meter was at least 5 years old and reading more than 30 mg/dl

As long as health authorities promulgate destructive "diabetes care" solutions like this, any health management program is going to make people with diabetes worse!

Scott S said...

I'd love to hear the explanation on denying you coffee, especially when there are studies which prove regular (not even decaf) coffee has beneficial benefits for most people, including those with diabetes. The "diabetes diets" for most hospitals makes prison food look healthy by comparison, so while its not surprising, it is nevertheless sad.

Anonymous said...

I was involved in a disease manglement program once, and after a month I declined further services. The asthma "managemnent" program consisted of sending me a home flowmeter with a chart of when I needed to use my rescue inhaler (I guess not being able to breathe was not a good enough indicator). The diabetes program consisted of sending me a new meter (I already had three at the time and brochures with weight-loss tips and sugar-free dessert recipes, and a nurse calling me once a week who clearly had no clue about diabetes itself, much less type 1. For instance, she had never heard of "dawn syndrome".

Unknown said...

They haven't managed to catch me at home and not online and they don't have my cell# so they haven't called me. I get reminders in the mail that I need an eye exam or a flu shot or whatever all the time. The chart with targets for everything I took to my dr and she marked them out and put in lower numbers.

They also have this online thing where you click on stuff and read and answer questions to help decide if you need what ever treatment you're trying to decide about. Or they did when we were first on this insurance. I never went back to see if it was still there.