April 29, 2000
HISTORY: ANTICIPATING IMPLEMENTATION CHALLENGES FOR eDM PROGRAMS
In the mid-1990s disease management
(DM) outsourcing companies attempted to integrate their services
into local delivery systems. They often encountered resistance from
local providers (physicians and hospitals), who viewed the DM
companies as outsiders.
Today a new wave of companies is
beginning to develop Internet disease management (eDM) offerings.
The challenge is similar: implementing and integrating eDM offerings
into local delivery systems, which are often resistant to
innovations of outsiders.
This essay will list and briefly
describe some of the challenges experienced by DM outsourcing
companies. We'll then describe the parallel eDM challenges. Finally,
we'll suggest some implications and next steps.
Challenges experienced by DM outsourcing companies include:
1) Lack of program standardization
2) Gashing the doctor/patient relationship
3) Insufficient preparation for the "Moment of Truth"
4) The "FedEx Truck Phenomenon": Resistance to clinical guidelines
Disease management did not even enter
the healthcare vocabulary until the mid-1990s. DM programs and
services were first promoted by pharmaceutical companies, primarily
to provide value added services to differentiate their drugs.
In the mid-1990s about 150 DM
outsourcing companies were funded, mostly by venture capitalists and
other equity investors.
DM outsourcing companies viewed
health plans as primary purchasers of DM services (on behalf of
their members). Services usually were organized around specific
regional markets. Typical services included implementation and
monitoring of care guidelines, medication monitoring, patient and
physician education, case management, telephonic counseling and
triage, and the like.
DM outsourcing companies experienced
major challenges in integrating their services into local health
care delivery systems. They were often viewed as outsiders. Their
initial business models were described as "carve-outs", and their
services were often viewed as taking away from existing local
Internet focused DM companies will
experience similar challenges in program implementation and
A similar dynamic exists for Internet
focused companies that are attempting to provide disease or care
management services. Many other types of companies are contemplating
providing DM services leveraging Internet technologies. (The
2000 issue of ECMN describes the wide variety of companies that
are showing interest in eDM).
This section lists four challenges
experienced by DM outsourcing companies a few years ago, and the
parallel eDM challenges existing today:
1) Lack of program standardization
antagonizes physicians. Here's what many physicians had to say about
DM companies entering their communities 5 years ago: "I have
contracts with a half dozen health plans and each of these health
plans has contracts with a half dozen disease companies. This drives
me crazy! Each DM company has their own way of doing things. I can't
deal with 9 different sets of guidelines for each disease, 9
different reporting formats, 9 different information systems, 9
different case managers constantly calling me."
What's the parallel eDM challenge?
Will physicians wind up saying: "All of these health portals have
developed their own disease management programs. I can't deal with
patients dragging in information from 20 different web sites, with
20 different clinical guidelines, in 20 different formats."
2) Gashing the doctor/patient
relationship. Health plans initially started with carve-out
contracting approaches with DM companies. A patient newly diagnosed
with a disease or new to a health plan could be faced with the need
to abandon her existing physician and establish a relationship with
a specialist that had a contract with the health plan or DM company.
Patient to the DM company: "I've been
diagnosed with cancer, am at one of most stressful points of my
life....and you insist that I change doctors to take advantage of
your DM program. Are you nuts....or just mean?"
Doctor to the DM company: "HOW DARE
you take a patient away from my practice!?"
The eDM challenge: Patient - "You
want me to go to a website instead of my doctor?????"
Doctor - "Your (health plan,
employer, DM company) told you to go to WHICH website and do WHAT!?"
3) Insufficient preparation for the
"Moment of Truth" The moment of truth occurs in the privacy of the
doctor's office between the patient and physician. The moment occurs
when the patient asks the physician:
"Doctor, I've been offered
participation in a disease management program by my (health plan,
hospital, employer, etc.). What do you think? Should I participate?"
How will the physician respond? DM
outsourcing companies initially did little to anticipate this moment
of truth, and all too often physicians responded "Dumb idea...ACME
DM company doesn't know what they're doing...forget it," rather than
"Great program....I heartily recommend it!" DM programs will live or
die by this moment of truth.
What's the eDM challenge? The patient
asks his physician "Doctor, I've been offered an Internet based
disease management program by my health plan, hosptial,
employer...it's at www.AcmeDM.com. What do you think? Should I
Will organizations engaged in eDM
take the needed steps to develop physician support? (A study
conducted by Laurus Health and referenced below noted that 67% of
the consumers polled considered health Web sites recommended by
their physician to be the most credible and trustworthy.)
4) The "FedEx Truck Phenomenon":
Resistance to clinical guidelines. An earlier edition of
News described the FedEx Truck phenomenon. In short, this refers
to the resistance incurred from local physicians when health plans
or disease management vendors have had the FedEx Truck simply drop
clinical guidelines off at doctors' doorsteps (instead of involving
them in development and implementation of the guidelines).
Physicians are still generally resistant to guidelines, particularly
to ones in which they have had no input.
What's the eDM challenge? The
Internet allows for 24 hour delivery of information - no longer is
it necessary to wait until 10:30 AM to affront your local doctor.
Every time a clinical guideline or algorithm is posted on the
Internet, it might be perceived as an affront to the to the way
individual physicians practice medicine today. Will physicians react
any differently to guidelines posted on web sites than they do to
one's dropped at their door by the FedEx Truck?
These are not easy issues to deal
Even the best thought out and
implemented DM outsourcing companies continue to struggle with the
issues described above.
...and while the safest way NOT to
challenge local providers is to DO NOTHING, that's certainly NOT OUR
RECOMMENDATION here. The spirit of this essay is to point out the
landmines ahead, not to suggest that you turn around and go home.
So, here are a few practical
suggestions of how to move ahead, yet in a way that offers the
greatest probability of achieving the "clicks and mortar"
integration promised by eDM programs:
1) Develop initiatives around local
markets. Health care is still provided locally. Successful eDM
initiatives will need to have a local market strategy and
implementation. While Healtheon initially developed a strategy
focusing on a national roll-out of its services, it has shifted to a
regional strategy with a medical trading area (MTA) focus. This
makes more sense.
2) Consider partnerships between
Internet based and local health care organizations. This could
include DM outsourcing companies, physician groups, health plans,
hospitals, etc. Remain unconditionally constructive if your first
overtures at partnership are rejected (and they often will be).
3) Involve local physicians early and
sincerely. The downside? This can take A LOT of time. The
alternative? The phrase "an elephant never forgets" was obviously
coined before someone crossed a doctor while implementing a DM
program. Many physicians are not inclined to offer second chances.
4) Think twice about doing anything
that is perceived as getting in the middle of the doctor patient
relationship. Ask "How can our eDM program support the
patient/doctor relationship, rather than divide it?"
"Fooled once, shame on you. Fooled
twice, shame on me."
DEMONSTRATION PROJECT STUDY - "BEST PRACTICES IN COORDINATED CARE"
Mathematica Policy Research has
Practices in Coordinated Care". The 176 page study examines best
practices in care coordination for Medicare beneficiaries with
chronic illnesses. The study also recommends design options for
anticipated demonstrated projects.
Why is this study important? The
Federal Government has made it clear that it would like to get out
of its current role as an indemnity health insurer for seniors. An
initial attempt to do this through legislation enabling Provider
Sponsored Organizations (PSO) generated little enthusiasm or
interest among providers. The Health Care Financing Administration (HCFA)
is back at it again by exploring alternative financing options for
care coordination services. This study is an early step in the
development of congressionally mandated demonstration projects.
A key conclusion of the study: "Our
findings suggest that care coordination holds the potential to
reduce health care utilization while maintaining or improving the
quality of care for chronic illness within the existing health care
The study makes five recommendations
for features of demonstration programs:
1) Programs should follow the three
steps (Assess and Plan, Implement and Deliver, Reassess and Adjust)
for all enrolled patients.
Step one should conclude with a
written plan of care.
Step two should include the
establishment of an ongoing care coordinator-patient relationship,
and the provision of excellent patient education.
Step three should include periodic
reassessment of patients' progress
2) Programs should have express goals
of prevention of health problems and crises, and of early problem
detection and intervention (a proactive approach, in other words).
3) Disease-specific programs should
incorporate national evidence-based or consensus-based guidelines
into their interventions.
4) Care coordinators should be nurses
with at least a bachelor's degree in nursing.
5) Programs should have significant
experience in care coordination and should have evidence of having
reduced hospital use or total medical costs.
BABY BOOMERS AND
SENIORS ARE FASTEST GROWING INTERNET USER GROUP
Media Metrix reports that the number of baby boomers and seniors
on the Internet grew by 18.4% last year, making them the fastest
growing Internet population.
AARP SURVEY OF
COMPUTER USERS AGE 45 AND OVER
The American Association of Retired
Persons (AARP) has released its "National
Survey on Consumer Preparedness and E-Commerce: A Survey of Computer
Users Age 45 and Older".
The study's findings suggest that
healthcare ranks in the middle among various uses of the Internet:
Percent Using Internet for Specific
Purposes (from Figure 8)
Product/service info............... 73%
Purchasing merchandise....... 53%
Real estate........................... 17%
Legal purposes..................... 10%
Other key findings:
Only one in three computer users
(32%) are "very confident" in their ability to use their personal
computers for financial transactions.
74% of those who have made
Internet purchases are concerned (40% "very" concerned) about the
privacy of information collected on them while they are making
purchases on the Internet.
Among all Internet users, nearly
eight in ten (77%) are concerned about their Internet activities
being tracked without permission, including 50% who are "very"
Four in ten computer users
surveyed (38%) rate themselves as "novice" computer users. Just
over half (54%) call themselves "experienced," while only 8% rate
themselves as "expert."
An overwhelming majority (93%) of
those surveyed believe that any personal information they give to
a business during a financial transaction remains the property of
the consumer and that the information should not be shared with
other businesses without the permission of the consumer, including
86% who "strongly" support this position.
A plurality of respondents (45%)
would not permit businesses to share their financial information
with other businesses under any conditions.
Implications noted by AARP:
Skill levels and confidence in
using the computer vary substantially in the 45+ population.
Confidentiality of personal
financial information is of utmost concern to this population.
Virtually all those surveyed believe that any personal information
given to a business during a financial transaction remains the
property of the consumer.
CREDIBILITY AMONG SOURCES OF INTERNET HEALTH CONTENT -- DOCTOR
RECOMMENDED SITES SCORE HIGHEST
A study from
LaurusHealth.com examined consumer perceptions of credibility
among health web sites. Key findings include:
67% of the consumers polled
considered health Web sites recommended by their physician to be
the most credible and trustworthy, followed closely at 61 percent
by Web sites sponsored by their doctor.
Health sites affiliated with
doctors and hospitals scored high overall, with 56% of consumers
trusting Web sites sponsored by their local hospital and 51%
trusting sites sponsored by an alliance of doctors and hospitals.
Consumers place the least amount
of credibility, according to the study, in sites that are
sponsored by a company that sells products via the Internet (9%).
Other health Web sites perceived
to be less credible are those consumers saw in a TV ad (13%);
sponsored by a pharmaceutical company (21%); and those identified
with the name of a famous doctor (28%).
Event sites recommended by a
friend were viewed much lower in credibility at 32% than those
affiliated with a doctor or hospital.
SPECIAL REPORT: HEALTH AND MEDICINE
April 3, 2000 issue of the Industry Standard contains a special
report - 14 articles relating to e-health and medical issues.
STUDY SHOWS SLIGHT
DECLINE IN BENEFITS OFFERED BY EMPLOYERS
A report issued by the
Human Resource Management (SHRM) shows overall decreases from
the previous year's survey in the number of employers that offer
Specific findings relating to health
care benefits include:
The number of employers offering
wellness benefits fell from 56% to 49%
Health screening programs continue
to be popular, especially among larger employers, but still fell
from 48% to 41% in 2000.
65% of respondents offer on-site
vaccinations (such as flu shots), an increase from 57% in 1999
PERMANENTE'S WEBSITE -- A LEADER IN DEVELOPING INTERACTIVITY WITH
The April 1, 2000 issue of ECMN
referenced a framework developed by
First Consulting Group.
The framework describes a Five Stages of evolution for health web
sites. The Five Stages are 1) Publish, 2) Interact, 3) Transact, 4)
Integrate, 5) Transform. Health plan sites were found to be
primarily in Stage 2, with a few pilots in Stage 3.
Kaiser Permanente's web site for members is a pioneer in
developing Stage 4 Integration among patients and caregivers.
E-CareManagement News is an
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