Managed Healthcare Executive - January 2009 - (Page 19)

{SPECIAL REPORT} Linden says. “Many other situations have not been settled quite so amicably. Rather than battle with vendors over the ROI every year, many MCOs have chosen to build their own programs.” They want more control over the interventions, and they are better positioned to coordinate care internally as well as with their provider networks. One of the major barriers for outside programs is physician support. “MCOs, as payers, naturally have an advantage in this area,” he says. “This advantage is even more pronounced with the introduction of pay-for-performance [P4P] initiatives and reimburse“If other industries are any indication, ment strategies for the medical home.” expect the demand for transparency to drive widespread changes in business There’s a push for greater practices and perhaps even the competitransparency tive landscape,” she writes. In a recent article in the Journal of Managed Care Pharmacy, Brenda R. Motheral, DM investment generally yields BPharm, MBA, PhD, calls for a revenue moderate ﬁnancial results model that aligns incentives between Current DM spending is at an optimal vendor and client; greater DM trans- level, says Al Lewis, executive director parency; more rigorous DM evaluation of the Disease Management Purchasing methodology; improved plausibility; Consortium International, Inc., (DMPand expanded evidence of improvement CI), in Wellesley, Mass., and MHE ediin outcomes. torial advisor. Most organizations should “There is an incredible amount of dis- not spend more on DM, but they should satisfaction relating to the performance not spend less, he says. and outcomes of these programs,” Mo“Beyond current spending levels, partheral tells MHE. “One of the most im- adoxically, further prevention would cost portant things to do is to push for greater more than cures,” he says. “If payers have transparency, particularly around en- extra resources available, they should be gagement and recording.” spending those resources on problems She notes that plan sponsors want other than common chronic diseases.” to know the number of members conLewis bases this analysis on DMPCI’s tacted, but this information often isn’t database of DM experience covering available because of limited vendor data. about 30 million lives. Validated methLarger, more sophisticated plan spon- odologies show that in general, DM prosors also want to know which members grams do save modest amounts of money, are contacted, how often, and via which Lewis says. However, cost-e ectiveness channels, so they can conduct indepen- varies depending on the condition. dent assessments of program e ective“It is a mathematical impossibility to ness. At present, neither call recording save money on asthma, because you have nor intervention notes are standard in- to spend so much on prescription medidustry practices. In the future, sponsors cines to prevent an ER visit, and perhaps might request a paper trail of metrics a two-night inpatient stay, which are not related to outcomes improvement, such very expensive,” he says. as changes in motivation, behavior, and In other disease categories, where the self-e cacy. cost of an event is much greater, it is pos- e U.S. system is actually winning the war on chronic disease sible to save money, he says. For example, one heart attack including follow-up care might cost $20,000. If a program can prevent that heart attack through lifestyle changes or statin use, it will be cost-e ective. Also for heart failure, where medications are inexpensive and exacerbations very costly, DM is often cost-e ective. “Our database shows that for these conditions, event rate reductions exceed the costs of disease management by 0.8 to 1.8 times the cost,” Lewis says. The United States is winning the war on chronic disease Lewis says he reached a surprising, controversial conclusion, which runs counter to all the conventional wisdom: The U.S. healthcare system actually is winning the war on chronic disease. He says that even though prevalence rates for chronic disease are increasing, event rates such as heart attacks, and procedures, such as bypass surgeries, are declining. In his opinion, this is thanks to a combination of disease management, plus improved care, better adherence to protocols, and improved pharmacopeia. He notes that asthma attacks have declined noticeably, and event rates for chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are at despite increasing prevalence. Diabetes event rates are rising slightly while the underlying prevalence of the disease is rising more substantially. “DM is working in the macro sense, meaning that the event rates are lower now that DM is widespread,” he says. “The system as a whole has done an outstanding job, and it hasn’t been properly appreciated.” Lewis commends NCQA. Pressure from NCQA on health plans leads to pressure from the plans on physicians to follow appropriate protocols. DM as an industry has broadly succeeded, he argues. “It’s paradoxical, because we can see noticeable improvement throughout the JANUARY 2009 4 2 3 19

Table of Contents Feed for the Digital Edition of Managed Healthcare Executive - January 2009

Managed Healthcare Executive - January 2009 Contents Editorial Advisors For Your Benefit News Analysis Politics & Policy Letter of the Law Managed Care Outlook New Day 5 New Realities of Disease Management Pharmacy Best Practices Health Management Technology State Report: Hawaii MHE Resource Ad/Edit Index

Managed Healthcare Executive - January 2009

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.