1 Health systems around the world are under increasing strain because of the rising prevalence of chronic conditions, including diabetes, heart disease, and asthma. For more than fifteen years, disease-management programs (DMPs) have been promoted as a solution to this problem. By carefully coordinating the delivery of high-quality care to patients with chronic conditions, the programs are supposed to enhance the patients’ health, reduce hospitalization rates, and lower treatment costs. Unfortunately, initial experience with DMPs was often disappointing. Many of them produced, at best, only modest improvements in health outcomes, and few were able to decrease health care spending. Thus, many payor, provider, and health system executives have questioned whether the programs are worth their cost. More recently, however, some DMPs have produced much better results. Germany’s diabetes program, for example, has reduced the incidence of some complications and has lowered the overall cost of care by 13 percent. Germany is also achieving good results with its programs for coronary artery disease (CAD) and chronic obstructive pulmonary disease (COPD). Several other countries have also begun to achieve good results with DMPs. Why have some DMPs achieved some or all of their goals while others have failed? To answer this question, we analyzed successful and unsuccessful programs to identify the differences between them. The key, we discovered, lies in the programs’ design; five characteristics markedly increase the likelihood that a DMP can both improve health outcomes and lower costs. Based on our results, we have developed a checklist that payor, provider, and health system executives can use to determine whether a DMP they are considering or are already sponsoring is likely to be successful—and what they can do if they spot problems. In most developed countries, three-quarters or more of all health care spending is now devoted to patients with chronic conditions, and a large portion of that money is spent only on a small number of diseases,
2 Disease management is an ideal way to reduce costs and improving quality of life by reducing disease in the United States population. Disease management begins with educating the patient of lifestyle choices and disease prevalence. The largest factor is getting everyone to work together. Working together means getting the patient involved with their care, the physician identify patients at risk and to explain the correlation of disease and lifestyle choices and getting the insurer to pay for it. Most patients want to pop a pill and keep engaging in unhealthy activities and either do not realize or care what the ramifications will be. It may be hard to engage the patient or to ensure the patient understands how to prevent or manage the disease. Everyone understands differently. The most successful programs have created public awareness and made attempts at showing the correlation of certain behaviors and diseases. The National Committee for Quality Assurance has created Standards and Guidelines for the Accreditation and Certification of Disease Management. The Centers for Medicare have created several pilot programs to treat and manage disease as they are one of the primary insurers. The ACA has also incorporated essential benefits into patients insurance to guarantee access to such prevention benefits. Most successful programs have started with creating awareness in the general public ie television ads, simplicity in design, data collection, and patient focused (Brandt, Hartmann, & Hehner, 2010). I have been made aware of through television ads are diabetes, blood pressure, obesity, COPD, and asthma. The first program is COPD and Brandt, Hartmann & Hehner, (2010) “The Veterans Health Administration has increased patients’ use of appropriate medications and lowered the rate of COPD-related hospitalizations and emergency-department visits” (Brandt, Hartmann & Hehner, 2010, para15). The second would be diabetes control by identifying at risk patients, discussing the disease with the patient, proper glucose monitoring and scheduled doctor visits and administering drugs to management disease (The Community Guide, last updated 2015).
3 The human/behavioral and economic impact of preventable diseases in the U.S. can be attributed to five chronic diseases; heart disease, cancer, diabetes, chronic obstructive pulmonary disease and stroke which are responsible for most deaths. Of these deaths, one third can be attributed to modifiable behaviors such as smoking, lack of physical activity and poor eating habits (Kongstvedt, 2007). Prevention as both financial benefits to employers (productivity /insurance costs) but also quality of life and decreased risk of mortality benefits to the employee. With only 2% of healthcare costs provided to the area of prevention and 70% of cost devoted to the treatment of people with chronic diseases that are most preventable it is evidence that more healthcare wellness efforts and resources (funding) should be scripted preventative care. Disease management programs may be beneficial in these cases through either primary secondary or tertiary prevention. Primary prevention focuses on preventative efforts before the disease starts, secondary is through surveillance and detection before symptoms began and tertiary addresses the disease once clinical symptoms are apparent in an effort to prevent complications from that chronic disease. Management of tertiary prevention is usually through Case management and comprehensive disease management efforts through employers, payers, ACO’s etc. Disease management programs help to guide in the care of chronic disease and improve quality of care of patients through insurers benefit selections such as incentives through co-pays, member services such as health risk assessments (HRA’s) which steer participants to appropriate programs to modify behavior such as for obesity or substance abuse. Other strategies include provider contracting through medical groups utilizing pay-for-performance incentives expecting evidence-based practices for preventative care. Influencing public policy is another effort that has been successful in legislating vaccinations for certain age related/high risk groups. Health reforms such as the Accountable Care Act (ACA) as legislating co-pay elimination or preventative services as well as workplace funding for wellness programs as an incentive for employees. ACA also included requirements for restaurants to display calorie counts on menus. A comprehensive chronic disease management program that provides education, ongoing support and oversight by health providers, strategies to promote patient engagement, supports to address social determinants that can be barriers not only to healthcare access but postacute resources to assist with patient accountability for their own health will be key (Russell,2009).
4 As healthcare approaches the $3 trillion mark for the country, “non-infectious diseases have replaced infectious diseases as the leading cause of death, illness, and healthcare costs” (Kongstvedt, 2007, p. 318). In addition to the direct healthcare costs, the top chronic diseases also cost billions of dollars each year due to lost productivity for the country. These diseases such as heart disease, cancer, stroke, diabetes and chronic lower respiratory diseases are partially to entirely preventable. The problem is that in order for prevention to be successful, significant personal behavioral changes would need to occur throughout society. Obesity and tobacco alone cost the country over a quarter trillion dollars by themselves. But trying to get people to stop smoking, eat right and exercise is a daunting challenge. The tobacco industry spends billions of dollars in advertising to sell their products (Federal Trade Commission, 2015) and the fast food industry caters to the fast moving lifestyle that Americans have created and fostered. It is a total up-hill battle. Plus, any investment that employers make today, won’t be realized for years to come. At that point, the employees may not even work for that same employer. So it’s a tough ROI proposition to sell to employers unless the government can incentivize companies to pursue prevention (which is not part of the ACA strategy). Disease Management (DM) programs can help guide in the care of chronic diseases and improve the quality of care for patients. One of the key components of the ACA is the move towards population health. DM programs, along with expanded case management resources, are beginning to tackle the management of chronic diseases head-on (Anderko et al., 2012). We have seen this at our hospital as well. We have added numerous case management style resources to work on transitions of care for high-risk patient populations.