Managed Care - November 2008 - (Page 20)

rectly to HMOs and employers. How much revenue in-house DM programs add to health plans’ bottom line isn’t known. The HIRC document also reported a survey of purchaser satisfaction and found that “the list of the most effective health plan DM programs on a national level has decreased, with only four plans nominated in 2008. This is because some large integrated national payers are reporting inaccurate outcomes data. In contrast, the number of mosteffective statewide or regional health plan DM programs has increased to 24. This may be attributable to strong physician networks.” Notwithstanding all that, even some regional plans are bringing DM in-house. Blue Cross & Blue Shield of Minnesota announced in May that it is launching its own DM program and ending its relationship with Healthways, a Tennessee-based DM vendor. The BCBSMN program will be telephonic and use computer searches of medical records. “These decisions depend on individual plan circumstances, such as scale and staffing goals,” says Gordon Norman, MD, executive vice president and chief science officer of Alere Medical, one of the nation’s largest disease management companies. His professional experience exemplifies the changes that are occurring in the disease management business. He joined Alere in 2005 when it purchased PacifiCare’s disease management business and became that health plan’s exclusive disease management vendor. PacifiCare is now owned by UnitedHealth Group, and United has its own in-house disease management unit, OptumHealth. But OptumHealth subcontracts with Alere to provide several DM programs. “There are advantages to in-sourcing and to outsourcing specific services, and that is what many plans are now doing,” says Norman. “They turn to outside vendors to provide services that are particularly difficult to manage, such as high-risk pregnancies which may require intensive heart monitoring, or behavioral health care, which may have an entirely different benefit design than medical.” “The industry has indeed become very complex,” says Tracey Morehead, president of what used to be called the Disease Management Association of America and is now named DMAA: The Care Continuum Alliance. “That’s why we changed our name. Our organization now represents a wide range of companies, including plans, DM vendors, pharmacy Challenges in DM models Challenges exist for plans in implementing disease management through vendors, and several exist regardless of implementation model. Here are some of those challenges and possible remedies, as outlined by THE DM expert Brenda Motheral, PhD, of the DM consultancy CareScientific in Brentwood, Tenn. Challenges and opportunities for DM purchasers Challenges Misalignment of vendor and client interests Insufficient transparency Insufficient plausibility More rigorous evaluation methodology Insufficient evidence of improved outcomes Strategies to derive greater value from disease management Move to a revenue model that aligns incentives between vendor and client Require greater transparency for engagement, interventions, and reporting Conduct plausibility tests, both prospective and retrospective Require comparison groups from nonparticipating groups, rather than from nonparticipating individuals • Expand outcomes assessment and contract requirements to include key clinical indicators (e.g., medication compliance) • Share findings with other purchasers Source: Motheral, Brenda. 2008: A Tipping Point for Disease Management. JMCP. Vol. 14, No. 7, 643–649. 20 MANAGED CARE / NOVEMBER 2008

Table of Contents Feed for the Digital Edition of Managed Care - November 2008

Managed Care - November 2008 Editor’s Memo Contents News and Commentary Legislation & Regulation Letters Medication Management Compensation Monitor Do It Yourself for Less Biomarkers Promise, but Do They Deliver? Oncologists Complain About Drug Payment Consider Blood Pressure Self-Monitoring Q&A: Keep Industry in the Game Formulary Files Plan Watch Tomorrow’s Medicine Outlook Respiratory Syncytial Virus Managed Care Considerations Contents Continuing Education Objectives RSV Disease in the Pediatric Population In the Trenches RSV Infection in the Adult Population Health Plan Medical Director Health Plan Pharmacy Director RSV Issues and Solutions Assessment/Evaluation/Certificate Request Post-Test

Managed Care - November 2008

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