Managed Care - November 2008 - (Page 22)

manufacturers. And their services are spreading into new markets, such as hospital systems.” Worth the cost? DM vendors are offering more services to more markets, but vendors are still having difficulty establishing their cost effectiveness. A recent commentary by Brenda Motheral, BPharm, of the DM consulting company CareScientific in Brentwood, Tenn., published in the Sept. 2008 Journal of Managed Care Pharmacy, states that DM companies still have to prove that they are cost-effective. “It does not really matter whether DM is offered by a health plan or a vendor; it remains an open question whether they established their effectiveness,” says Motheral in an interview. “They still need to establish, for example, that they can function transparently and have proven outcomes.” BEHAVIORAL HEALTH CARE Mental health case management outcomes data are hard to come by. Kongstvedt points to the fact that “particular expertise is needed to successfully manage the clinical aspects of mental illness because the treatments are unique.” Management of many mental illnesses, for example schizophrenia, is often done by specialty companies even when a plan maintains an in-house behavioral health program. But the management of depression, which often accompanies chronic diseases like congestive heart failure and diabetes, by an integrated internal program has clearly demonstrated cost effectiveness, says Kongstvedt. “It is in the ability to manage the complexity of disease states that disease management is the most valuable. Depression management is a good example of the possible advantages inherent in an internal, integrated program.” Aetna ended its relationship with Magellan, the dominant managed behavioral health company, in 2004. Last year it reported some meaningful outcomes in the internal program it developed, the Medical/Psychiatric High Risk Case Management Program (Med Psych). Med Psych targets members who have concurrent medical and behavioral health conditions, particularly diabetes and depression. The program evaluation looked at medical, pharmacy, and utilization costs over one year and compared members who were enrolled in the Med Psych pro- “It does not really matter whether DM is offered by a health plan or a vendor; it remains an open question whether they establish their effectiveness,” says Brenda Motheral, BPharm, a disease management consultant. gram with those who were not enrolled. The study looked at claims data for 2,737 Aetna HMO members and 1,834 Aetna PPO members. Aetna Behavioral Health, the wholly owned company that runs Med Pysch, demonstrated a total behavioral cost savings of $136 per member per month when members were enrolled in the program compared to members who were not enrolled. In addition, medical costs for these depressed diabetic patients decreased by $175 PMPM. Pharmacy and antidepressant costs did rise ($39 PMPM and $11 PMPM, respectively) for members enrolled in the program. A post evaluation of enrolled patients showed an increase in self-perception of physical and mental health as measured by SF12 scores. (The SF12 is an industry-standard, 12-item, self-administered questionnaire that assesses symptoms, functioning, and quality of life.) The primary way a fully integrated behavioral/medical model differs from a vendor model is that there is no distinction between physical and behavioral health. Benefit structures are combined, financial risk is pooled with risk for medical services, and a common provider network is established. With a vendor, there would be a distinct behavioral health panel managed by that vendor. 22 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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