A Founding Father of DM Astonishingly Declares: “My Kid is Ugly”

Al Lewis, one of the founding fathers of DM, has shaped the face of the DM industry probably more than other any single individual. (This is all fine unless you happen to be the person whose face is being shaped by Al.)

Al has been unabashedly pro-DM.  Until now.  Al writes in a recent article in Managed Healthcare Executive:

Disease management as we now define it may be on its last legs, though no one knows it yet. The Disease Management Purchasing Consortium has noticed that the savings in all but a few diseases doesn’t offset the costs, and nowhere does it generate the level of return on investment (ROI) that some people think they are getting.

But fear not, Al foresees a new DM:

The good news for the DM industry is that just as organizations are figuring out that they are measuring wrong, a revolution from within is replacing this old model. The new model will bring far more impact, more easily measured for the buyers. …

Al describes that the essence of the difference in the emerging model of DM is a higher integration of services:

The new model works because it is vastly more inclusive than the old. It doesn’t just involve chronic diseases. It combines wellness, 24/7 nurseline, preference-sensitive conditions, complex case management, and care coordination into a one-stop shop. Most importantly, it promises to bend the trend, not just on chronic care events (which make up surprisingly little of many employers’ health spend, according to Health Dialog), but on the entire healthcare budget.

Where Al and I Agree

As we learn more about what works and what doesn’t work in DM, there’s no question that higher levels of integration lead to better financial and clinical outcomes.  No disagreement here.

The DM industry learned its first lessons about the need for integration back in the late 1990s when most single disease companies gave way to companies that managed multiple diseases.

We’re learning the integration lesson again in understanding that DM is not an island — that ideally it should be part of a broader population health management approach within an employer and/or health plan population as Al suggests.

Where Al and I See Things Differently

I’d agree with Al that the need for higher levels of integration is a driving force in chronic disease management. However, I don’t believe that Al’s new model takes the integration far enough.  Al suggests the need to integrate services across a broader membership of the employer and/or health plan population

That’s fine as far as it goes, but I believe that the real integration opportunity will be in integrating services with health care providers.  More specifically, I’m referring to better integration of health care providers in chronic disease management workflow, enabled through integrated information and communication technologies (ICT).

Dr. Emad Rizk of McKesson describes the necessary additional step in an interview with Managed Care Magazine:

I believe the old definition of disease management, which often boils down to a nurse call center, has run its course. There will be a merging of technology, products, and services, to create a new disease management paradigm. The new model that will evolve is a fuller medical management utilizing multiple interventions and technology, including personal health records and electronic health records. We’re starting that now.

The opportunity to integrate health care providers through shared workflow and ICT will be most pronounced in the Medicare population.   The lack of integration with local providers is one way to explain the lack of successes in early Medicare DM demonstration/pilot projects (BIPA, the Medicare Coordinated Care Demonstration (MCCD) and Medicare Health Support (MHS)).

HOW this integration will occur is the real question.  Will providers lead the new DM? …or will they simply participate through shared workflow and ICT?

Your thoughts?  Al? —  shyness is not one of your issues.

5 thoughts on “A Founding Father of DM Astonishingly Declares: “My Kid is Ugly”

  1. One can’t argue with the need for more integration…we have talked about this for years. But things take time to evolve. The current trend in the rapidly growing self-funded employer DM market to contract directly for DM services has lead to these same employers asking DM companies to also provide their wellness programs. Soooo….DM companies have been buying up wellness companies and in some recent cases have almost gone on record as saying that “they are really a prevention company” [no names mentioned]. The need/desire for more integration has also fueled what appears to be a growning “trend” towards insourcing DM, at least by health plans.

    To better understand where the DM industry may be going, one needs only to look at the international markets…and to take a look at the Wagner Chronic Care Model that is takes the idea of integration into the community. The Wagner model has been extremely well received outside of the United States. Companies like McKesson and other successful Medicaid DM companies understand this need for community engagement and integration.

    Aside from increased integration, I believe taht the future DM/Wellness programs will have both “more touch” and “more technology” with the touch also being supported by the new technology.

    All this “new model” talk aside, market watchers are not surprised that the industry is evolving…that is what new markets do. The successful companies will be those that have the resources needed to change their game and can be “light on their feet.”

    I only wish that our DM products had evolved fast enough to be successful in the Medicare Health Support pilots. It is of great concern to the industry that we are struggling in many/most of these pilots. This apparent “bump in the road” could also have a negative impact on the exporting of DM experience to other countries as these countries are carefully watching how the US DM industry does in the Public Sectors, Medicare and Medicaid. Companies that are successful in these public markets will be those that will have the greatest success international. The IDMA was formed to help bridge US experience into international markets and vice vesa. Our weekly report is designed to report on chronic disease management and prevention aroung the globe. See http://www.dmallinace.org, or view the recent April 25th issue at:
    http://www.magnetmail.net/Actions/email_web_version.cfm?publish=newsletter&user_id=IDMA&message_id=301419

  2. I am often not sure if Al Lewis is teasing us, but it does seem amazing to read his capitulation done so breezily.Is he really admitting that the Emperor may Have No Clothes? I disagree with his new model since it so correct, and so holistic, and does not help much.
    I have held for some time that DM as a theoretical concept is very good, and am a strong supporter, but the following are some of the problems;
    -The patients’ doctors are not involved,
    -There is minimal IT integration and information sharing between DM vendor and doctors’ offices,
    – Stratification, predictive modeling, aka Finding the members who need real DM is very difficult,
    -Getting compliance or adherence is very difficult without a good reason, such as having the member know his/her doctor is really involved,
    -we confuse DM (early disease)with Care management(late, complex, many co-morbidities)
    And so it goes………..

  3. Shyness is right up there with shortness in not being one of my issues. I read the comments with interest and noticed that thw two criticisms were opposites, one saying that I hadn’t gone far enough and the other saying I was too quick to abandon the model. A few observations:

    (1) As to not going far enough, in theory I couldn’t agree with Vince more. In practice integrating the docs might be years away. It’s hard enough to even find practicing physicians who know which of their health plans even have DM with which vendors, and what the programs do, and refer people to thm. So Vince’s vision would be great but is still years away.

    (2) As to breezily abandoning the model and whether it still works, I was way ahead in saying that it did work (all the benefits consultants were saying the opposite) and I think I may be equally far ahead in saying it doesn’t (the benefits consultants now being strong believers) but here’s what happens in practice. A small portion of people are called, an average of about 3-4 months after their diagnosis, asked the same questions that their doctors asked, read some information off a protocol, and then maybe given some helpful information and possibly, more and more, some motivational interviewing…and then the health plan or employer is told they got a 4:1 ROI.

    Remember, new theories of evolution suggest that it is much more likely to be disrptive than linear…and it’s now time for the next major disruption. If I have to break a few eggs to help make this omelette, let’s just say I have experience in that and I’m willing to do it again.

    I might add that almost every major vendor has written to me about this article. most think that they are already one of the three examples of the next wave I described but all of them want to be.

  4. Having worked in this industry for the past 7 years most of it spent with the market leader all of the points that have been made are valid. The reason the market has not moved is because the financial incentive to do so has not made it a priority. I think many of my co-workers looked at me as if I had lost my mind when I changed companies over a year ago. I left because I knew what was behind the curtain and I knew what I needed to learn to stay ahead of the market. I know the following problems that have not been addressed and will need to be before the market moves:

    1. DM, care management, care enhancement, decision support, health/care whatever you want to call is being delivered at the wrong end of the healthcare value chain. The health plan /payer is the last stop on the chain. That is our first challenge we will always be 10 steps behind if we work from that end of the value chain (it includes self funded employers also).
    2. Wellness is not the key and neither is integrating wellness and DM. The key is looking at the whole population and creating system that has the ability to deliver variable interventions and incentives across the entire populations. It is more than the combination of programs it is finding out how to improve a persons health status and its beyond education and gym discounts.
    3. No one has cracked the physician directed dilemma yet, but we are getting closer. The physician has all the data we need to operate proactive management programs. The challenges is how do we access that data and how do we pay the physician for this.
    4. Technology exists today to collect and deliver interventions in a more cost effective manner. The reasons why the industry has not embraced these technologies vary greatly, but one stands out the most. In my opinion we have been hung up on making DM as clinical as possible we have basically over engineered everything. Why should nurses make welcome calls? Why should nursed administer an HRA? Why are we using clinicians for jobs that can be automated or leveraged using RPM, IVR and other automated solutions?

    In my opinion the physician directed care management will be the next market and I am in full support of the points Vince has made. Al I am wondering why you can see that the employer self funded is already saturated and looking at from my angle all the major employers already have programs in place and are just trying to consolidate programs so they can have one vendor. Also Al I would disagree that physicians are not ready they are already dabbling in DM. All you have to do is go the AMGA and MGMA to find out what group practices are up to.

  5. I’m a UK MD and the chronic disease management is just hitting our shores. All of the resources here are being shifted into the community.
    Hospitals are closing beds

    The system is modelling itself on US healthcare delivery, which is probably no bad thing.

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