Disease Management Comes of Age, Not a Moment too Soon

Initial attempts to maximize the impact of care for chronic disease often proved to be empty promises. Effective variations on the theme, however, have arrived just in time to battle double-digit health care inflation.

By Annmarie Geddes Lipold

Queasy at the thought of double-digit health care cost increases? It's a chronic condition, but a potent new form of the disease management concept can at least alleviate symptoms and may even offer a cure.

Disease management, which manages individuals' health conditions to ensure optimal care and treatment, has been around for at least a decade. Traditionally offered through health plans, disease management was part of managed care but many programs never delivered on their promises, says Sean Sullivan, president & CEO of the not-for-profit Institute for Health and Productivity Management in Scottsdale, Ariz.

Now, however, disease management is coming of age; it is evolving into a proven and effective way to make employees healthier, while saving employers crucial health care dollars. But what exactly is disease management?

The Disease Management Association of America (DMAA) defines it as "a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant." According to the DMAA, disease management should support the practitioner/patient relationship and plan of care; emphasize prevention and complications by using proven guidelines and patient empowerment strategies; and evaluate clinical, humanistic and economic outcomes to improve health.

To the DMAA, "full service" disease management programs should have: population identification processes; evidence-based practice guidelines; collaborative practice models to include physician and support-service providers; patient self-management education; process and outcomes measurement, evaluation and management; and a routine reporting/feedback loop. Programs consisting of fewer components are referred to as disease management support services.

Disease management "is all about getting health care providers and patients to do what is proven effective for the treatment of a disease," says Chuck Reynolds, principal at The Benfield Group, a St. Louis-based consulting firm specializing in health and productivity. Like factory equipment, health is an asset that can be managed effectively to benefit employers and their employees, he says. Disease management is a tool to that end.

It's also a necessary tool, since patients don't always follow doctors' advice, and physicians' recommendations aren't always consistent with best practices. Nowadays, employers are implementing disease management programs because they're taking the "longer view" and recognizing — out of financial necessity — the importance of managing the costly diseases of their aging baby boomer workforce, Reynolds says.

A recent survey, The Takeda and Lilly Prescription Drug Benefit Cost and Plan Design Survey Report, revealed that 44 percent of 468 employers surveyed had disease management programs in 2000. The results, released in October 2001, show employer use of disease management has held mostly steady over the past three years. Some of the most frequently used disease management programs target diabetes, asthma, heart disease and high blood pressure.

Market shifts

"When disease management came on the scene, everybody and their brother thought they could do it," says Reynolds. It turns out, however, that the application of effective disease management was tougher than many thought.

Currently, the disease management industry is "demonstrating a new ability to help employers identify and manage their costliest medical problems," Sullivan says. Disease management providers are starting to measure more than medical costs, he says. There's also the savings that result from reducing the "burden of illness" — such as reduced absence and diminished job performance.

A new development in the field has employers contracting directly with disease management providers, says Warren Todd, president of the Washington, D.C.-based DMAA. There are about 200 disease management-related service programs available to employers, he says. Health plans, hospitals, pharmacy benefit management companies and pharmaceutical companies provide disease management services in addition to the companies that specialize in disease management.

Employers can buy a nurse outreach program to help employees manage high cholesterol or opt for a more comprehensive package that includes provider outreach, education and measurement, and that reports what care was delivered and how effective that care was, says Brian Schilling, communications and marketing director for NCQA. "It is the brave new territory of health care," he adds.

Some vendors provide effective disease management for very specific ailments, such as asthma or diabetes, while others are moving toward "health management," which helps employees with multiple health issues achieve an "optimum state of health and functionality," Sullivan says.

The natural consolidation into "one-stop shopping" comes from the recognition that it is more effective to treat "the patient and not just the disease," Todd says. It also eliminates the need to deal with multiple vendors.

Technology is also boosting what disease management vendors can offer, Reynolds says. Through the World Wide Web, disease management companies can communicate with patients inexpensively, asking them to record certain data on a regular basis. Patients, he adds, can be prompted by e-mail messages.

There is also increasing integration of the Web with medical devices, such as glucose monitors and scales. This data feeds directly back to the disease management company, which uses it to help manage patient treatment and identify broad health trends.

Some vendors are so confident that disease management saves money, they're willing to share the risk, Reynolds says.

Getting results

Employer participation in such programs may be stagnant, however, because of a dearth of hard data to prove the ability of disease management to reduce overall health care costs. Rather than a means of cost savings, "employers participating in disease management programs tend to think of it as the 'right thing to do,'" the study found.

Some employers, however, are showing beneficial results from disease management, including health care savings. Consider The Kellogg Company, which realized a 30 percent drop in mental health care costs one year after implementing a disease management program.

The company asked the vendor managing its Employee Assistance Program to begin handling mental health cases, says Joe Alberding, MD, vice president of medical affairs for the 10,000-employee cereal and snack food company. Based in Battlecreek, Mich., Kellogg posted nearly $7 billion in sales for 2000.

When implementing the program in 1999, Kellogg took a "leap of faith" by publicizing and encouraging employees to use its mental health benefits with the idea that early intervention would hasten recovery, thereby saving money in the long run. The effort resulted in a 10.8 percent participation rate at its peak — well above the national norm, he says.

The company initially intended the disease management program to give employees an advocate in the treatment process and eliminate treatment barriers, Alberding says. The company's Employee Assistance Program was the entry-point for use of mental health benefits. Case managers worked with the company's already-established network of trained mental health specialists to ensure the best care for employees.

"We got them the care they needed more promptly, which reduced the duration of treatment and costs," he says. But saving money was not the company's main motivator, Alberding adds. "We sold it with, 'This is the best way to take care of our employees and, by the way, it will save money.'" The company plans to use this model to manage other diseases, including diabetes, asthma and hypertension.

Lockheed Martin Aeronautics' disease management program is showing results by saving time employees would otherwise need to take off for medical treatment, says Pamella Thomas, MD, medical director for the aircraft manufacturer's 6,800-employee site in Marietta, Ga. Overall, the Fort Worth-based company has 20,000 employees and posted $4.9 billion in 2000.

After instituting a disease management program for diabetic employees at its on-site clinic, the company realized savings of more than $600,000 in sick time — about two hours of sick time per month — for just 300 employees one year after implementation, she says. But there is another advantage to disease management: Surveys show that employees feel the company cares about them and their health concerns, she says.

Lockheed Martin also has disease management programs for coronary artery disease, high blood pressure and a "men's health initiative" that includes prevention and treatment of prostate cancer and hepatitis C. The disease management program provides early detection and follow-up that encourages employees to get treatment immediately and to stick with treatment. Otherwise, she says, these patients might not seek help as soon as they should. The Lockheed Martin program is managed mostly in-house, she says. (For more details on Lockheed Martin's "men's health initiative" program, see our related article, also in this issue.)

While Lockheed Martin found success by managing its program in-house and Kellogg found that outsourcing disease management meets its needs, both approaches prove to be the answer for International Truck and Engine. The company offers disease management programs for conditions ranging from diabetes to musculoskeletal injuries and is experimenting with a comprehensive disease management program for both non-occupationally and occupationally related illnesses at one site.

Off-the-shelf programs do not work for the company because of its unique employee population, says Dr. William B. Bunn, vice president of health, safety and productivity for the Chicago-based truck manufacturer. With 17,000 employees in North America, the company posted $8.5 billion in sales for fiscal year 2000.

Because the company has to design programs to meet its employees' special needs, it first studies the needs of the employee population and then develops a program that responds to employee health needs, he says. (For more details on the International Truck and Engine program, as well as tips on how to set up your own program, see our related article, also in this issue.)

Venturing into the marketplace

For employers like Kellogg that outsource disease management, finding the right vendor with credible results can be a challenge.

Disease management, says Alberding, is an "immature industry." The tools necessary to do it well are not widely available or perfected. "We have people out there doing a number of things and calling it disease management," he says.

Out in the field there are differing definitions for disease management, which can further confuse employers. Disease management vendors offer everything from support services to comprehensive programs, which can also make it difficult for employers to find a proven program that suits their needs.

Three organizations — NCQA, URAC and The Joint Commission on Accreditation of Healthcare Organizations — have worked separately to develop standards for disease management companies because there are currently no national disease management standards. Each organization says its standards were developed to improve quality and safety of patient care.

"Large employers don't really know how to evaluate these programs and would like guidance on which ones they should do business with," says Schilling.

Last December (2001), NCQA began listing companies that have shown interest in becoming accredited or certified in its program; one has already achieved full accreditation.

URAC also released a draft of its standards in December for public comment, followed by the final standards' approval in April 2002. The "first wave" of accredited companies and in-process applicants will be announced in August 2002. URAC's standards, says Liza Greenberg, vice president of research, call for providing "a common framework for accountability for the diverse organizations offering disease management." The standards focus on evidence-based care of chronic disease, patient education and collaboration with physicians and patients.   

In February, the Joint Commission launched its disease management standards, called "Disease-Specific Care Certification," and awarded the first disease-specific care certificate in the country.

The acceptance of standards should help employers make better choices, experts say. The DMAA also provides tips for employers interested in disease management. (Click here to view the DMAA's tips.)

As disease management continues to grow into its own, experts encourage employers to consider the approach — but to do so carefully. "I think employers should go slow," says Todd. "It's not as simple as it looks."

Resource Links:

Disease Management Association of America
http://www.dmaa.org

The Takeda and Lilly Prescription Drug Benefit Cost and Plan Design Survey Report
http://www.pbmi.com/bdsr_detail.asp

The National Committee for Quality Assurance (NCQA)
http://www.ncqa.org

Institute for Health and Productivity Management (IHPM)
http://www.ihpm.org

URAC
http://www.urac.org

The Joint Commission on Accreditation of Healthcare Organizations
http://www.jcaho.org