QUALITY: DSM–Alive and kicking?

A while back I wrote about the VA and its care management program and in that post I noted that DSM appeared to be getting bigger but wasn’t sure as to whether it was a big deal. I took that discussion over to the very active DM Forum list-serv and it spawned a great deal of posting, which by now has veered off into the realm of Chaos Theory and non-iterative prisoner’s dilemmas. But in the brief period before the philosophers took over and while it stayed on message there were some interesting responses.

The most interesting was from Al Lewis who’s Disease Management Purchasing Consortium essentially owns the research and RFP-type consulting in the space. As no one else is really looking into this as a research business, I find that to be a proxy for it being a small market. I suggested to Al that as Gartner, Forrester, Advisory Board, Harris, Datamonitor etc hadn’t made much of run at it, as a derived anecdote, it suggested that this isn’t that much bigger an area of focus than it was 5 year ago. Al responded to me that “the field has been growing at 22-25% annually and for 2004 will exceed $800-million (including postacute patient mgmt). “ The recent news that market leader American Healthways has seen its revenue in 2003 grow 35% to $165m probably bears out Al’s estimate. In another reply later he suggested that the internal use of DSM was broadly equivalent to that spent externally. So one can guess that roughly a little under $2bn is being spent on disease management programs. To put it in perspective, if the entire DSM business was a drug, it would be less important than the second ranked Cox-2 inhibitor. You can get much more data and information from Al (although it will cost you actual money–as it should!). He also noted that:

The reason these other orgs haven’t made a run at it (or me) is that I pretty much own the space. The DM companies are private for the most part–I’m the only one who can estimate their revenues because I get their RFPs with average pricing and # members. And in the case of the Advisory Board at least, this isn’t their market–no one on the hospital side will spend a lot of money to learn about this field.

Again that’s all true, but if the market was ten times the size Al would find more competition in his niche. But the bigger question is even if it’s growing relatively fast from a small base, has DSM lived up to its promise of becoming a real market? On this broader point Al writes:

The Disease Management Purchasing Consortium tracks revenues by vendor and has been doing so since well before “Monica Lewinsky” was a household name and I can tell you with drop-dead certainly that the field has been growing roughly 25% a year.

It’s a little like soccer. How, might you ask, is disease management like soccer? Well, when I was a kid all the big tough kids (the ones who were getting to third base in sixth grade but who now mostly sell used cars, or, if they are lucky, quality pre-owned vehicles) played football at school. Our school offered soccer to the rest of us, to keep us off the streets (since we listened to the Monkees, that’s how cool we were, I’m afraid the streets would have had little to fear from our being on them in any case). Well, when one of our parents friends or some other random adult asked what sport we played and we said “soccer” we had to explain what soccer was. Likewise, seven years ago when you said you were in “disease management” you had to explain to people–even people in managed healthcare–what disease management was. Now, even ordinary cocktail-party-type people kinda sorta know. That, my friend, wouldn’t be happening if the field weren’t growing by leaps and bounds.

Now Al’s current style belies his alleged 6th grade wimpiness. I grew up playing soccer in the UK–it’s a real hard man’s game there–and there are plenty of fat, bald middle-aged men limping around London who wish they hadn’t run into a dirty central-defender called Holt in their youth. And for that matter, if you saw the Olypmic women’s soccer final, you might have noticed some pretty rough stuff being dished out by both the Americans and the Brazilians, and The Guardian indicated that the Americans kicked the Germans off the field in the semis. That’s what less talented but very determined teams do to win in sports. (England’s 1966 World Cup Win is a case in point)

However, to return from that little digression, you might think of taking Al’s point about DSM and soccer getting more important in the US together. But it would have been more convincing if it hadn’t been tested by another poster who said that “I was at a cocktail party just last night and happened to mention disease management and the general response from folks was: ‘but, isn’t that what doctors do?’ David Tinkelman, MD from the National Jewish Medical and Research Center backed up the cocktail party folks:

Some times, people who work in the provision of healthcare services called “Disease Management” forget the reality that this small intervention is but a part of the larger world of management of disease. In that world, the reality is that the principal relationship is between the patient and a physician (not necessarily an ongoing relationship, as in those who primarily seek their care in emergency rooms and clinics). It is in that relationship that medications are prescribed, care is administered,prevention is applied and presumably trust is established. Most external entities who provide “disease management” services do not provide medications directly, hands on care, and take direct care and responsibility of emergency and life threatening situations. These have been and are the roles of the physician community. To believe that outside entities really provide management of disease without direct physician input is putting on blinders to the reality of the healthcare system as we know it in the United States.

But on the other hand Robert M. Ross, MD wrote:

I am not completely convinced that physicians “have” to be the lynchpin in the process. I have been involved in too many DM programs that achieved remarkable results without and sometimes despite physician involvement. However, for those that cannot live without them, there is no option other than Pay to Play programs. Yes, there are some physicians who will strive to do everything for their pts, but for most, it is not practical or financially sound.

So–assuming that DSM programs aimed at patients outside their interactions with physicians can only get us so far–it appears that we’re stuck in a world in which the doctors can’t or won’t get involved, but are needed to make the big changes. So what do the doctors need? Obviously incentives is one thing. But another is technology to support DSM in the clinical workplace. The CHCF had a roundtable looking into IT use in Chronic care management which reported this week.

Funnily enough the report was written by my colleague Robert Mittman who spent the 1990s being the most pessimistic person I know about the adoption of IT in the clinical setting, and may have been too optimistic! The report is an excellent summary of the state of play, and it basically says that in the small to medium sized physician’s practice–that is where most Americans get their health care–we are nowhere. Or rather we are just starting on incomplete disease registries, and hoping the eventually they’ll get built into the ever-coming but not quite here electronic medical record.

Now there is a very important reason that these efforts should continue, and Medicare can help by changing the way it pays for DSM but that’s a tricky process. In the meantime we have more independent confirmation in Health Affairs from Ken Thorpe that 15 big disease categories consumer most of the money we spend on health care, and many of them like diabetes, heart and lunch disease are in the wheelhouse of DSM’s successes to date.

But I hate to remind Al that while around the world soccer is just getting bigger and bigger as a sport and as a business, in the US the women’s pro league folded last year, and the men’s game is a sickly 7th or 8th in terms of TV time and fan importance despite a 1/4 final-round appearance in the 2002 world cup for the men, and sustained success for years for the women. So just because something should be a big deal, it doesn’t mean it is. But let’s hope it will be.

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