Nailing the Coffin Shut?

Lots of buzz this week about disease management. First, Archelle Georgiou, MD, proclaims the “The Death of Disease Management (Finally).” Archelle’s arguments seem reasonable enough if you don’t consider that her post-mortem describes a DM model so outdated that today’s providers likely wouldn’t recognize it. Al Lewis reinforces that point with his excellent rebuttal – one with which I actually agreed. (I will, ahem, set aside for another day my thoughts on his position regarding outcomes methodology.)

Then, today, the Congressional Budget Office weighs in with a report on all the Medicare demonstration projects testing “disease management, care coordination, and value-based payment” models. Guess what? CBO says DM didn’t reduce Medicare spending in any of the Medicare demonstration and pilot programs. Really? This is news? Not at all.

The eight-page CBO Issue Brief released this morning summarizes a 30-page report, and I direct your attention to it: It contains a wealth of information that backs up much of what we, the population health management industry, know and that reflects program models being implemented today, in 2012.

Certainly, news reports will proclaim this yet another nail in DM’s coffin. Yet, the full report contains much about which we should crow – and loudly. The full report details the individual strategies upon which each demo or pilot was built and which of those strategies had more success than others. In addition, the report discusses the potential for success and the weaknesses of the studies due mainly to sample size. News flash: Many of the strategies that were more successful are the exact strategies that form the foundation for today’s programs. Further, (and here’s the really wonky part) the report correctly points out the confidence intervals for each study and suggests that, due to the large size of these CIs, we really don’t know how successful or unsuccessful each of these programs really were.

Bottom line: Today’s CBO report is a clear road map on how to build effective programs for Medicare populations. Remember that we can learn as much from what works as what does not work. This is a great road map for our industry and one, frankly, we’ve followed turn-for-turn in recent years.

A final point: Archelle noted, “At the end of the day, DM that does not achieve a net savings is not successful.” It’s an astonishingly cynical conclusion, especially juxtaposed with her “About Me” commitment to “health care projects, initiatives, and causes I believe are most meaningful to making a difference for people.” So, saving money is the only way to make a meaningful difference? Consider this counterpoint, published in the January 2008 American Journal of Managed Care and penned by former Care Continuum Alliance Chair Gordon K. Norman, MD:

“Let us return to the question of whether the current excess of $1 billion spent annually for DM is a good investment. Let us suppose that it is eventually shown by replicated RCTs that, in aggregate, DM programs consistently improve clinical outcomes, quality of life, functional status, and worker productivity but do not invariably produce cost savings. Might it still be the case that DM is consistently cost-effective? If that were the case – and many DM experts believe that it is plausible – it would be noteworthy because little of what physicians do to patients is ever cost saving (albeit life saving). Medicare is not allowed to consider cost-effectiveness in approving new technology for reimbursement, and the US Food and Drug Administration must approve any new drug shown to be safe and effective regardless of cost or comparative effectiveness. Few would question whether health plans should conduct case management, whether hospitals should provide discharge planning, or whether physicians should educate patients about prevention and healthful lifestyles, but none of these accepted health interventions have been shown by replicated RCT evidence to be consistently cost saving or cost-effective, to my knowledge.”

Bingo. Few health care interventions have been shown to save money, yet no rational person would suggest, for example, an office visit with a physician is “not successful” or bypass surgery is “not successful.” A more responsible measure of success might be whether the intervention creates value – in other words, whether you get your money’s worth. It’s the same yardstick we hold up to most other transactions, from a grocery store purchase to a new home. In that light, the evidence is clear that the right disease management intervention for the right population at the right time improves clinical outcomes (and, despite what disease management’s pallbearers would have you believe, can save money).

Where does that leave us? With a vibrant industry that continues to grow and evolve, as evidenced by the rapid pace of recent acquisitions and investments. There’s clearly value to be derived from current population health management strategies in new care delivery models – we see that in the quality improvement drive in the Medicare Advantage Star Ratings program. While I’m sure we haven’t yet heard the last post-mortem on these outdated demos and pilots, when they do crop up we can’t help but think of that memorable Saturday Night Live Weekend Update line, “Generalissimo Francisco Franco is still dead.”

—Tracey Moorhead, President & CEO

2 Responses to Nailing the Coffin Shut?

  1. Pingback: Is Disease Management dead? Or, should we wait a bit before nailing the coffin shut? | The Doctor Weighs In

  2. Pingback: Can We Really Buy Savings in Healthcare? « health, wealth and happiness

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