October 22, 2002
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REPORT: MEDICARE RECOGNIZING CHRONIC CARE CHALLENGES, CHAMPIONS
Will Medicare embrace disease
management (DM) approaches? Medicare and lawmakers are doing their
homework on DM, and it’s revealing to review some of their notes
along the way.
Numerous expert witnesses recently
testified before the U.S. Senate Special Committee on Aging. The
Committee examined "Disease Management and Coordinating Care: What
Role Can They Play in Improving the Quality of Life for Medicare's
Most Vulnerable?" We read testimony from Congressional
hearings so that YOU don’t have to; however, if you're curious you
can review text and video testimony by clicking
(scroll down to 9/19/02).
The expert testimony shows that 1)
Government officials are recognizing the impending challenges of
baby boomers with chronic conditions, and 2) that diverse DM
champions are emerging to carry the banner.
"HOUSTON, WE HAVE A PROBLEM"
This well known distress call from
Apollo 13, especially familiar to boomers, summarizes the
Congressional Budget Office's new realizations about America's
impending chronic care challenges.
by Dan L. Crippen, Director of the U.S. Congressional Budget Office
(CBO) reveals a new understanding of the budget problems facing
"...fiscal pressures will only
accelerate as a result of the aging of the baby-boom generation...if
current law remains unchanged, CBO expects that spending for
Medicare will more than double...by 2030.... Addressing these fiscal
pressures is one reason policymakers have expressed interest in
adding a disease management benefit to Medicare."
As part of its homework, CBO compiled
a longitudinal database of Medicare patient expenditure data from
1989 to 1997. Crippen noted that "CBO's effort represents a
significant enhancement over currently available data."
...and what does the new data show?
First, the new data shows
CONCENTRATION of expenditures.
In 1997, the costliest 5 percent of
beneficiaries consumed about half of total Medicare spending, and
the costliest 25 percent consumed almost 90 percent.
Second, the new data shows
PERSISTENCE of expenditures.
"Focusing in further on beneficiaries
who were among the most expensive quarter of enrollees for two or
more consecutive years allowed CBO to look at beneficiaries who were
persistently expensive over time -- and whose care might be amenable
to better coordination. That group accounts for a large amount of
Medicare spending. In its preliminary work, CBO found that from 1993
through 1997, such persistently expensive beneficiaries accounted
for 19 percent of enrollees but 57 percent of Medicare spending. In
other words, their spending was three times the average for all
beneficiaries and nearly six times the average for beneficiaries who
were not persistently expensive.
"...Preliminary findings suggest that
persistently expensive beneficiaries ...are indeed more likely to
have those profiles -- that is, they are more likely than other
beneficiaries to have been diagnosed with coronary artery disease,
congestive heart failure, diabetes, chronic obstructive pulmonary
disease, asthma, and end-stage renal disease."
In plain old English, CBO has figured
out that people with chronic conditions 1) cost more in any given
year, and 2) cost more over time. (Those of us who have been
following DM for a number of years need to remain patient and
understand that it takes time for the political process to play out.
We should resist the temptation to characterize or color Crippen's
statements as "The CBO's exploration has discovered some preliminary
evidence that the earth might NOT be flat and that it is, in fact,
round. CBO awaits conclusive studies.")
While Crippen does show new
understanding of the problems facing Medicare due to aging baby
boomers with chronic conditions, does he believe that DM approaches
are the solution? "We remain to be convinced," declares Crippen.
The potential evidence to do the
convincing is being developed in 15+
Medicare Coordinated Care Demonstration Projects
currently under way. These projects could provide the type of
evidence needed to expand DM benefits to Medicare.
DM CHAMPIONS ARE EMERGING.
Within Medicare, Ruben J. King-Shaw,
Jr. is emerging as a cheerleader for DM. King-Shaw serves as Deputy
Administrator and Chief Operating Officer, Centers for Medicare &
Medicaid Services. His
testimony at the Senate
hearings shows vision and perspective.
"The almost complete absence of
disease management services in the traditional Medicare plan is
another striking indication of how outdated Medicare's benefit
package has become.
"Disease management is a critical
element for improving the nation’s health care and its delivery
system. Along with the Secretary, the Administrator and I want to
take full advantage of all of the opportunities for increased
quality and efficiency that disease management offers."
As an important footnote, politicians
on both sides of the aisle are lining up to support innovative
disease management approaches.
Senator Larry Craig (R-ID), Ranking
Member of the U.S. Senate Special Committee on Aging, voiced his
support for DM. "The potential for disease management is phenomenal.
It holds the potential to improve the quality of life for Medicare's
most vulnerable seniors, and it may reduce health costs. That's why
I called for this hearing."
Senator John Breaux (D-LA), Chairman
of the Committee, echoed his support. "Disease management programs
are valuable to both physicians and patients. By educating people
about their illness, disease management programs empower patients
and provide a mode of care that prevents the complications often
associated with chronic diseases."
Other diverse constituencies also are
voicing support for DM. A conservative think tank, The
Heritage Foundation, recently
pointed out that "traditional Medicare does not provide for sound
coordination of care or disease management programs. These kinds of
specialized programs are often found in private-sector health
New Democrats Online has
written in support of DM. For example, it recently reported on North
Carolina Governor Mike Easley's efforts to design a DM program to
deal with the problem of low-income seniors who need prescription
drugs to treat serious, chronic diseases.
To summarize the dialogue to-date:
Crippen: "We understand that Medicare
has a problem with aging baby boomers. Show us the evidence that DM
is a solution."
King-Shaw and others: "We are
developing the evidence and we will make DM happen!"
FAILURE REPORT CARD SHOWS NEED FOR PHYSICIAN AND PATIENT EDUCATION
“Heart Failure Report Card Executive Summary”
Conducted by the University of Pittsburgh and Thomas Jefferson
University with support from AstraZeneca LP, September 2002
The Executive Summary reports on
physician, patient, and general public interviews relating to heart
failure knowledge and treatment.
Physicians gave an overall letter
grade "C" to how heart failure is being diagnosed and treated in the
United States. They graded patients’ understanding of heart failure,
understanding of treatments, and compliance with making lifestyle
changes a "D+."
PROMOTES VALUE OF DM IN SOLVING HEALTH CARE CRISIS
“Health Care At the Crossroads”
National Association of Manufacturers (NAM), September 2002
This report summarizes health care
cost and quality perspectives of 800 manufacturing companies. For
manufacturers, these issues promise to take on even a larger role
than in the past:
- The rising COST of health
care...comes at a time for manufacturers when any additional costs
cannot be absorbed by profits or passed on to customers.
- Because manufacturers provide such
a high level of health benefits for their employees, they are
interested in the levels of QUALITY they can offer. ...97 percent
of NAM members voluntarily offer their employees health coverage.
The report provides seven
recommendations toward better future health care:
1) Expand employee participation in
wellness and disease management.
2) Collaborate to reduce medical errors.
3) Bring a HHS (Health and Human Services) voice to health care.
4) Move benefits administration to the Internet.
5) Pave the way for group purchasing arrangements.
6) Put Congress on the right health care track.
7) Use financial incentives to reduce health care costs in the long
Unlike many large Fortune 500
companies, most manufacturers have not participated in active health
care quality management initiatives. One exception is in disease
management, where large and small companies alike are investing in
the promotion of the health and wellness of their employees (p. 31).
Online disease management is another
area that shows great promise of both reducing costs and improving
quality. Nearly 20 percent of NAM members make online
disease-management programs available for a specific disease (p.
RESEARCHERS REVIEW HEALTH PLAN CARE MANAGEMENT PRACTICES IN 12
“Back To The Drawing Board: New
Directions In Health Plans' Care Management Strategies”
Health Affairs, September/October 2002
Concluding remarks from the “Policy
Health plans' approaches to care
management have changed substantively; the changes we observed are
more than just posturing by a tarnished industry. Overall, the
changes shift the “management” of care away from management of all
or many enrollees toward management of smaller groups of sicker
We found consensus among plans that
the growth of disease management has improved the care experience of
participants, and many respondents believed that their programs were
improving quality of care.
“Integrating Technology and Disease Management -- the Challenges”
Healthplan Magazine, September/October 2002
This article discusses challenges
faced by health plans attempting to integrate technology into
1) Effective Patient Targeting
2) Integrating Data with Nurse Workflow and Care Management
3) Demonstrating Return on Investment
“The State of Health Care Quality: 2002”
National Committee for Quality Assurance (NCQA), September 2002
the Business Case for Improving Mental Health Care
How to Maximize Corporate Resources”
National Health Care Purchasing Institute, September 2002
“While Managed Care Is Still Unpopular, Hostility Has Declined”
Harris Interactive; October 21, 2002
Your PDA a Health Partner
Manage disease, get fit, or just be ready in case of emergency”
BusinessWeek Online; October 7, 2002
Future of Healthcare is Everywhere
The coming revolution in pervasive computing may be closer than most
of us realize—and it is likely to have a profound impact on
healthcare and the medical device industry”
Medical Device and Diagnostic Industry, September 2002
“2002 Annual Employer Health Benefits Survey”
Kaiser Family Foundation, September 2002
“Partnership with Providers Leads to Better Asthma Care”
Center for Health Care Strategies Spotlight, September 2002
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