People are living longer and getting sicker, and providers are facing the difficult question of how to care for them. In an effort to better fight a slew of diseases and help cut down on costly hospitalizations, many providers are turning to disease management.
"As baby boomers get older, more and more care is involved around chronic conditions," says Vince Kuraitis, founder and principal at Boise, Idaho-based Better Health Technologies, LLC., a managed care consulting and business development company. "It's not, 'Come in and take your kid in who's got a broken arm.' It's, 'I've got diabetes and I'm going to have diabetes for the rest of my lifetime.â€™â€
People with chronic conditions tend to be the ones to utilize the healthcare system most, Kuraitis says, for their chronic condition and acute hospital care. Managing chronic disease requires moving away from a system of centralized care to a decentralized one, he says. It's one with a different set of rules, one which is not designed for when "you get in an accident or you get a cold and the doctor fixes you, and you go away."
But the goal of disease management is not just to stem the number of physician visits, says Al Lewis, president of the Wellesley, Mass., Disease Management Purchasing Consortium International Inc. The goal, he says, is to modify them. "If disease management is working, the number of doctor visits stays about the same, but the agenda for the visits becomes way more appropriate," Lewis says. "Patients go to the doctor when they need to, and don't when they don't; as opposed to now where sometimes they go when they don't need to, and don't when they do need to."
It's all about data
The Department of Veterans Affairs (VA) is not new to disease management. In 2005, the number of people who received care at a VA facility topped 5.3 million. According to Michael Mayo-Smith, M.D., acting director for primary care at the Veterans Health Administration of the VA, almost all of the people seen have chronic conditions, "and many have three or four or five of them."
A decade ago, the federally funded capitated health system implemented a primary care system, expanded outpatient care, and created an electronic medical record (EMR) to better manage its chronically ill.
Disease management at the VA starts with primary care physicians tightly managing patient conditions. Built-in EMR "clinical reminders" help physicians to ensure patients get proper care — in one case, diabetic eye exams.
The clinical reminder searches through all the codes in the EMR and identifies diabetics. It searches the records to find the last eye exam. If, for example, the exam was 11 months earlier, the physician is alerted.
"The alert comes up while I'm seeing the patient and offers me options," Mayo-Smith says. With the reminders, the doctor can see if an exam has already been scheduled, order a consult, or document that the exam was performed outside of the VA.
"What happens is the physicians get busy," he says. "The patients come in because they have a cold, because they hurt their shoulder, and all these chronic disease things are happening in the background. Nobody comes in with the complaint, 'Oh, I have to have a diabetic foot exam.â€™â€
Aetna enters the fray
Unlike the VA's system that relies on primary care physicians and EMR clinical reminders to manage the chronically ill, Hartford, Conn.-based Aetna's uses doctors, nurses, predictive-modeling outcomes and a 14-terabyte database.
According to Margaret Dee, R.N., clinical director of disease management programs at Aetna, Middletown, Conn., the insurer helps patients develop an action plan so that they know what to do if something changes in their condition. "They know when to call the doctor versus heading off to the emergency room, or sitting home and getting worse and ending up having to have a hospital admission," she says.
After managing six conditions with its Aetna Healthy Outlook program with services provided by LifeMasters Supported SelfCare, a South San Francisco disease management company, the health plan created Aetna Health Connections to manage 30 conditions through risk stratification.
Aetna's program identifies members who have a chronic disease for which there is effective treatment, but for whom there is a gap in care, says James Cowan, M.D., head of clinical programs and operations for Aetna Health analytics in Blue Bell, Pa. Using software acquired from New York's Active Health Management, Aetna identifies and assesses diseases, members and treatments to find the sickest members who would most benefit most from a change in treatment.
"What it does actually is it creates an opportunity score, which is really a measure of actionability," Cowan says.
"Every month, based on claims, data and information that's been shared with us, we actually have a predictive model which assigns a score to that member," Cowan says. "That score represents the likelihood of high medical costs to that member in the next 12 months." Zero is the lowest; 10 is between $25-50,000; and 14, $250,000 and up.