Dr.Rearick

It describes ten large experiments conducted in enhanced primary care, case coordination and disease management for frails elders conducted in the 1990s.

One of the findings was that financial payback occurred in two or three years, but not sooner.

Another conclusion was that frail elders are – for the most part – on a one way declining slope. On average the rate of decline can be reduced, but cannot be reversed.

1. As a physician who practiced the first 20 years I feel justified to point out, if physicians practiced evidenced based medicine, using information systems that allowed good quality of care management there would never be a reason for any Disease Management vendor. Shouldn’t a person’s personal physician be the primary entity responsible for disease management? Let’s put some of this energy into fixing the system where it should be fixed–at the physician/patient interaction.

Second: Measuring a financial ROI is just the wrong measurement. I would much prefer a comparison of average medical/Rx PMPM costs, neutralized for age/sex/demographics/and benefit design between populations involved in DM and comparable populations NOT invovled in DM. If a neutralized PMPM is beating medical trend for the managed population and all the “plausibility factors” are moving in the right direction, then it can be assummed that a real VOI, or Value On Investment is taking place as a result of disease management activities. Our firm does this regularily to show why DM is not only the right thing to do, but how a well run program improves the health status of a population. Measurement people (like myself) have to focus on utilization, quality of care AND financial measurements to show real value–not just ROI. Medicare should do the same.

Dr. Rearick

All of us know population of age above 75 with multiple chronic conditions is difficult to manage, not only due to their complex medical needs but also due to their reluctance and inability to adapt new lifestyle.

Among this population, would the biggest saving come from 1) lifestyle education, 2) emergency risk triage, 3) medication management, 4) elimination of unnecessary treatment, or 5) avoidance of institutionalized care?

does it work for them? they say it does? they have convinced their employer customers it does

dm gets a trial from the super friendly bush admin and republican congress with a low expectations program

they did not deliver what they said they could do, in a program environment favorable to them

dm is a good idea

maybe the champions of dm ought to focus on health outcomes

maybe the champions of dm ought to think about their model and stop relying on the “direct marketing tactics” of their call center strategy

At the end of the day, if it turns out that few conventional medical interventions match the cost-effectiveness of DM interventions (in terms $ per QALYs) yet we reject the value of DM because it failed to meet negotiated yet arbitrary savings target for these pilots, it will be a shame. Yes, let’s stay the course on MHS until we understand all the outcomes and drivers, while also exploring other approaches to improving the value of healthcare for Medicare.

Improving value in healthcare (where Value = Quality/Cost) is no small feat; perhaps the best that DM can do for this frail population is to improve health and QOL in a cost effective fashion. That would be a disappointment for many, but should not be interpreted as a failure in the larger context.

But, aren’t there areas where we’d expect SOME short term gains? For example, there have been dozens of studies documenting the ability of preventing readmissions for heart failure patients. If MHS was going to be successful, wouldn’t we expect to see short term gains here? ….yet we don’t (see p. 41 of the RTI report).

Gordoon, as always thanks for your well reasoned points.

However, I’m missing the punchline,i.e., the implications of your statments. Can you elaborate on your point “Still, one wonders if the evaluators, CMS staff, Administration officials, or the general public will pay sufficient heed to the value equation when those clinical and financial outcomes are more mature. “

Are you suggesting that we “stay the course”? if so, does that mean staying the course with MHS specifically or staying the course in looking for solutions for Medicare’s broader chronic care challenges?

The conventional wisdom is that we have a cost crisis in healthcare today; others have rebutted that there is nothing intrinsically wrong with a country spending 16% or 20% or more of it’s GDP on healthcare if it chooses, assuming it values the results of those expenditure very highly relative to the
alternatives. (For now let’s skip the interesting question of how voluntary is our “choice” to spend this amount on healthcare.) However, what is nearly
universally agreed by policy wonks and pundits alike is that we don’t derive sufficient value from our current healthcare investments to merit the
current level of expenditure, much less an even greater amount of GDP. We need improved healthcare value for money, so we should work to improve the
quality outcomes we get for the same expenditure, pay less for the current level of quality, or some combination of both.

The initial report to Congress on the MHS pilots is careful to caveat its findings with cautions about the very limited duration of program impact for
this first 6 month period of observation. Nonetheless, the report contains speculative conclusions that focus much more on the “price of everything” than on its value. Of course, it is too early to evaluate health outcomes at this stage and the MHSO contracts do have highly publicized financial targets
that are not yet being met, as expected. Still, one wonders if the evaluators, CMS staff, Administration officials, or the general public will pay sufficient heed to the value equation when those clinical and financial outcomes are more mature.

It’s very premature to get cynical about the potential impact of disease management on the health and economics of Medicare beneficiaries, based on the
limited information available from the MHS pilots. Getting better value for our healthcare expenditures is what these pilots should be all about. Let’s
hope that CMS is guided by this perspective with various R&D initiatives in the area of disease and care management for seniors. These chronically ill beneficiaries certainly deserve no less, and th same could be said for all of us who pay for healthcare.