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CCH® BENEFITS — 1/14/08

Disease Management Effectiveness Called Into Question

From Spencer's Benefits Reports: There is no conclusive evidence that disease management either reduces medical costs or improves long-term health outcomes, concluded the authors of an article published in the December 2007 issue of The American Journal of Managed Care. Disease management does appear to improve the quality of care (except for asthma and chronic obstructive pulmonary disease) and reduces hospitalization rates for patients with congestive heart failure.

For the article, “Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?,” three researchers affiliated with RAND Health and the Cincinnati Children’s Hospital & Medical Center reviewed 317 studies on the subject, but focused on the outcomes of 29 studies, three of which were large, population-based programs (that identify and target all patients with a given condition regardless of severity) and 26 were small-scale programs. In the United States, nearly all (96%) of the top 150 health care payers and 83% of more than 500 employers offer disease management programs. In 2005, the disease management industry took in nearly $1.2 billion in revenue.

Among the disease management programs, the researchers examined the following three dimensions:

1. severity of illness among the target population, because the scope of programs has expanded to include all patients with a condition regardless of severity and at patients with rare and costly conditions (such as hemophilia and autoimmune disorders);

2. intensity of the intervention, because programs vary widely from low-intensity interventions (which emphasize mass communication technologies such as mailings and prerecorded telephone messages) to moderate intensity interventions (which include more direct individual contact such as telephone calls from call centers) to intensive case management (including face-to-face encounters between patients and disease managers); and

3. the targeted medical condition, because, “although disease management will always strive to improve care and patient outcomes, whether it can save money by doing so may depend on the targeted disease.” The researches also observed that disease management programs “vary by other important attributes such as the integration and involvement of the patient’s primary care physician and the presence of financial incentives.”

The article’s authors describe disease management as “a system of coordinated health care interventions and communications to help patients address chronic disease and other health conditions.” Based on the selected studies, the researchers reviewed the effect of disease management on congestive heart failure, coronary artery disease, diabetes mellitus, asthma, chronic obstructive pulmonary disease, and depression.

Study Results

The authors found that while disease management appears to have no effect on utilization for the targeted conditions, it does increase outpatient care and prescription drug use for patients with depression. The evidence is inconclusive as to whether or not there is behavior change due to the disease management intervention, although the studies reviewed found improvements in disease measures for all of the medical conditions examined except for asthma and chronic obstructive pulmonary disease. Furthermore, although hospitalization rates dropped for congestive heart failure patients, they rose for patients with depression. Evidently, patient satisfaction and quality of life improved only for depression, but it was not conclusively evident for other conditions.

The authors found “no conclusive evidence that disease management leads to a net reduction of direct medical costs. However, the strength of this conclusion is limited because many studies do not address the issue of cost but focus on quality of care and outcomes; and many studies have methodological flaws, such as the incomplete accounting of costs and the absence of a good comparison strategy.

“Our findings suggest that a dynamic and innovative industry has outpaced its underlying science and that substantial efforts will be necessary to allow the evidence to catch up with product development. The Medicare Health Support Demonstration will greatly enhance our knowledge when final results become available in approximately 2010. Results reported in the first interim report showed that not one of seven vendors could meet its performance guarantee of 5% net savings, and two vendors withdrew from the demonstration” the authors concluded. “Until a stronger base of evidence has been developed, public and private purchasers of disease management services should be skeptical about vendor claims and should demand supporting evidence based on transparent and scientifically sound methods…The results of our review suggest that, to date, support for population-based disease management is more an article of faith than a reasoned conclusion grounded on well-researched facts.”

For more information, visit http://www.ajmc.com.

For more information on this and related topics, consult the CCH Pension Plan Guide, CCH Employee Benefits Management, and Spencer's Benefits Reports.

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