May 2, 2001
BUY-IN -- THE "ACHILLES HEEL" OF DISEASE MANAGEMENT
by Harry Leider MD, MBA
Why is achieving physician buy-in
important to successful implementation of a disease management
It is my experience that programs
that fail to gain widespread physician support have great difficulty
enrolling patients and usually experience enrollment rates less than
40%. Conversely initiatives that enjoy strong physician sponsorship
can achieve enrollment rates as high as 75%.
As a case in point, while I served as Medical Director of HealthNet
(a regional managed care organization in Kansas City), we
implemented both asthma and CHF programs at approximately the same
time. The asthma program was provided by a disease management
company with outstanding outcomes that invested little effort in
achieving broad physician buy-in. Conversely, HealthNet worked with
another firm to create a CHF program that actively engaged
cardiologists and primary care physicians.
The enrollment rates were vastly
different -- the asthma/COPD program rate was less than 50% while
the CHF program's enrollment rate was over 80%. The CHF program had
higher rates because cardiologists ACTIVELY referred patients to the
Why is achieving physician support so
difficult? The core issue is that physicians inherently value
autonomy. Disease management strategies SEEM to directly challenge
the professional autonomy so valued by physicians.
In reality, most disease management
programs don't supplant the central role physicians' play in caring
for patient with chronic illness. Instead, they increase compliance
with a prescribed regimen and monitor patients between visits to
So What Are the Core Tactics to
Achieve Physician Buy-In?
Based on observing successes and
failures of many programs that have tried to engage physicians, we
have developed six core tactics for achieving buy-in for disease
management programs. These are:
1) Providing Education
2) Enlisting Champions
3) Creating A "Box"
4) Building On Success
5) Sharing The Gains
6) Giving Them Tools
1) PROVIDING EDUCATION
Physicians need to be reassured that they will maintain their
professional autonomy and central role directing the care of
patients. Physicians generally respond positively when they review
outcomes data from programs that have significantly improved quality
of care and reduced costs.
Educational efforts must stress that
good outcomes are achieved through a combination of good physician
care supplemented by extra tools (e.g. patient education, compliance
monitoring, electronic home monitoring, etc.) by the disease
Considering the limited time most
physicians can devote to learning about disease management,
educational efforts must be varied in form and repetitive.
2) ENLISTING CHAMPIONS
Enlisting champions is a systematic approach to attain visible
support from opinion leaders within a local medical community.
Doctors make decisions in an autonomous fashion, but also respect
the opinions of experts.
One effective approach to enlisting
champions is to create a physician advisory committee for each
disease management program. The role of the advisory committee can
include providing input on: the decision to build vs. outsource the
program, choice of a vendor, modification of clinical guidelines,
patient identification, and effectively implementation tactics.
Most physician advisors become champions by becoming intimately
involved with the program!
3) "CREATING A BOX"
Despite limited experience and infrastructure, often physician
groups will refuse to support a disease management initiative unless
THEY provide the program.
The tactic of "create a box" deals
with this and has two basic elements. The first element is to
articulate the value proposition offered by an experienced vendor.
Having one or more companies present their programs to the
interested group of physicians easily accomplishes this.
The second element is to use this
data to create a set of criteria that the physicians must meet. For
example, for congestive heart failure, a quality disease management
company should be able to launch a program in 90 days, guarantee a
10% to 15% savings (net of the cost of the program), and deliver
high levels of patient satisfaction. The physician group is then
offered the opportunity to be the "vendor" if it can meet these
In most cases, provider organizations
do not have the infrastructure to initially meet these criteria.
Often, a compromise is reached where: 1) the providers agree to
support the initial use of an outside vendor, and 2) they receive
assurances that they can become the vendor when they develop the
4) BUILDING ON SUCCESS
This is simple tactic whereby an organization demonstrates to
physicians that earlier disease management initiatives have
To execute this tactic it is important initially to target diseases
where it is relatively easy to achieve good outcomes. For example,
asthma and congestive heart failure are relatively easy programs to
implement while HIV, diabetes, or low back pain are more difficult.
Factors such as the presence of co-morbidities, involvement of
multiple specialists, and presence of poorly aligned financial
incentives make it more difficult to implement a disease management
program for certain diseases.
Most physicians view a track record
of successful programs as a persuasive argument to support a new
disease management initiative.
5) SHARING THE GAINS
The goal here is to share the financial gains produced by disease
management programs with the participating physicians. Organizations
can do this in a variety of ways. Providing "case management fees"
to physicians to compensate them for the time they spend interacting
with care managers is one simple and effective approach. More
complex financial schemes such as bonuses programs or "gain sharing"
models can be used to create powerful incentives for physicians to
support and participate in disease management programs. Finally,
providing selected physicians a stipend for creating clinical
guidelines or supervising care managers is another reasonable
approach to sharing the gains.
6) GIVING THEM TOOLS
Disease management programs that make it easier for physicians to
care for patients with chronic disease are usually well-received.
Simple, well-designed patient specific reports, judicious
interaction with case managers, data from electronic home monitoring
devices, coordination of benefits or home services are all tools (or
services) that support physicians in managing patients with severe
Many disease management vendors have
deluged physicians with paperwork, faxes, phone calls, care plans,
and guidelines. They have missed the boat on making life easier for
the harried physician by providing tools and services.
PUTTING IT ALL TOGETHER
EVEN IF the tactics discussed above are used effectively, the
process of achieving broad physician support is challenging and time
It is our experience that these tactics are most effective when they
are employed by physician leaders who are CREDIBLE, PERSUASIVE, and
As mentioned earlier, the CHF program
implemented by HealthNet employed ALL 6 TACTICS to achieve buy-in.
Extensive educational initiatives included newsletters, lunch
meetings, a physician advisory board and individual discussions with
skeptical physicians. Initially several cardiology groups and
hospitals felt that they could provide a CHF program. After they
learned of "the box" of criteria that included guaranteeing savings
and demonstrating outcomes, the cardiologists were open to working
with a disease management vendor. Subsequently, cardiologists from
the major groups were employed as medical directors for the program
and supervised the program's nurse practitioners/case managers.
Primary care physicians and
cardiologists were compensated with case management fees. This
program also followed the successful launch of programs in asthma,
COPD and high -risk maternity care.
Achievement of physician "buy-in"
truly is the Achilles heel of disease management programs.
Organizations implementing disease management programs should employ
all of the six tactics outlined in this article. Ultimately, only
organizations that are successful at working with physicians and
achieving their support will achieve truly outstanding outcomes.
Contact Harry Leider, Principal,
Better Health Technologies at firstname.lastname@example.org or (410) 252-7361.
TRUCE! -- AMA,
JCAHO, and NCQA AGREE ON COLLABORATIVE CLINICAL GUIDELINES
Who says cats and dogs can't get
along? The American Medical Association (AMA), the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO), and the
National Committee for Quality Assurance (NCQA) have released
collaborative guidelines on diabetes care.
JCAHO, NCQA News Release; April 25, 2001
"Coordinated Performance Measurement for the Management of Adult
Diabetes" Consensus Statement
This is good medicine. The LACK of scientific, agree-upon clinical
guidelines perpetuates fragmentation in US health care.
This is good business. While none of
these three organizations INDEPENDENTLY has enough clout to issue
guidelines that are likely to be accepted as standards, their
issuing guidelines TOGETHER greatly increases probability of
acceptance and implementation. Patients are better served when
clinicians, delivery systems, and their accrediting organizations
agree NOT to compete over clinical standards.
INCENTIVES TO IMPROVE QUALITY -- HANDWRITING ON THE WALL
"Aide: Bush Medicare Reforms to Focus on Quality"
Reuters, April 12, 2001
Remarks from Dr. Mark McClellan, advisor to President Bush:
"We really want to make healthcare
quality a primary focus of the president's healthcare agenda."
Upcoming White House efforts to
reform Medicare are likely to include financial incentives to
hospitals and doctors who successfully reduce medical errors and
improve the quality of patient care.
Some health care purchasers have
already experimented with financial performance incentives to
improve quality. For example, see
Performance Incentives for Quality: The State of the Art"
National Health Care Purchasing Institute, September 2000
"Medical Management and the Internet: Views of Managed Care Leaders"
Cap Gemini Ernst & Young (CGE&Y), April 2001
CGE&Y interviewed information and medical management executives at
12 managed care organizations. Some of their major findings:
The current market for medical
management applications is focused on administrative functions,
such as eligibility, referral, authorization, formulary, and
claims look-up functions.
Some potential exists in the
short-term (1-2 years) for point solutions that address specific
medical management functions (e.g., physician profiling) and for
wireless and handheld devices.
In general, payors view medical
management as a longer-term system development initiative (i.e.,
2+ years in the future). Applications that directly involve the
consumer and transform how care is delivered and managed are still
several years off.
What's NOT at issue is the critical need for payors to enhance
medical management strategies.
What IS at issue is the timing and
phasing of implementation plans...this report does a good job of
surfacing many of the complexities involved.
AD -- CHRONIC
DISEASE STRATEGY WORKSHOP
The Institute of Medicine's (IOM) recent report advises that
"Common chronic conditions should serve as a starting point for the
restructuring of health care delivery."
Have your management team, board, or physicians wrestled with the
potential upside and downside implications of ever-increasing
chronic disease? Do you have a strategy in place?
More than 70% of medical costs are
spent on patients with chronic conditions. "Chronic Disease
Management: Bridging Clinical and Business Strategies" is a
customizable workshop available for your organization. Faculty for
this workshop are
Harry Leider MD, MBA and Vince Kuraitis JD, MBA.
Contact Vince Kuraitis at (208)
"Current Issues Report: Approaches to Depression Care. Health Plans'
Innovative Programs in Depression"
American Association of Health Plans, March 2001
This report highlights health plan successes in depression
Advances in treatment guidelines
Improvements in depression
detection, diagnosis, and treatment compliance.
Better clinical outcomes.
Enhanced provider recognition of
The development, funding, and
implementation of high-quality, strategic research projects.
Focusing on early detection,
referral, and treatment for postpartum depression.
E-HEALTH INVESTMENT OPPORTUNITIES
From Early Mistakes in E-Healthcare"
VentureWire, April 26, 2001
FastCompany, April 2001
DIABETES AND PRODUCTIVITY
"Productivity Losses Associated With Diabetes in the U.S."
Diabetes Care, February 2001
CONCLUSIONS - Diabetes has a considerable net effect on earnings,
and the complications and duration of diabetes have compound
effects.... the presence of complicating factors is the single most
important predictive factor in lost productivity costs attributable
to diabetes, and thus the avoidance or retardation of complications
will have an impact on indirect health-related costs.
FRAMEWORK FOR A
NATIONAL HEALTH CARE QUALITY REPORT
National Health Care Quality Report"
Institute of Medicine, March 2001
As important as this topic is, only the most dedicated reader will
be able to stay awake -- all others should stick with the executive
Disclosure -- No clients were
mentioned this issue.
E-CareManagement News is an
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