Reports of the Death of Disease Management Are Greatly Exaggerated

Al LewisThere have been unsavory rumors flying around the internet that disease management as practiced today may not be all that effective. I’m not going to reveal who started these rumors but her name rhymes with Archelle Georgiou. This person says disease management is “dead.” Since there are still many disease management departments operating around the country apparently oblivious to their demise (and disease management departments are people too, you know), I suspect this commentator was using the word “dead” figuratively, as in: “The second he forgot the third cabinet department, Rick Perry was dead.” (Another example of presumably figurative speech in the death category would be: “After he denounced gays while wearing the Brokeback Mountain jacket, you could stick a fork in him.”)

And if the rhymes-with-Archelle commentator intends “dead” as a synonym for “not in very good shape,” she certainly has a point. Not only does she have a point, but I would add more items to her list of reasons for the field’s current troubles:

(1) The interval between diagnosis (the point where readiness to change is usually greatest) and successful patient contact can exceed three months;

(2) Predictive modeling “risk scores” that tell you only how sick someone was, dressed up as a “risk score,” not how sick they will be, even though they aren’t already high utilizers;

(3) Some interventions are so expensive that they exceed the cost of the disease;

(4) The physicians are still not involved;

(5) Rather than using actual mathematically sound methodologies to calculate results, many vendors and consultants damage the credibility of the entire endeavor by believing in the Outcomes Fairy.

Fortunately, there are improvements afoot to address all of these issues:

(1) Electronic medical records presage faster claims adjudication, and ICD-10s will mean much more detailed patient information than is possible today. And disease management departments are already coordinating with UM/precertification/discharge planning better than even two years ago. Together, these innovations will match people with programs much faster;

(2) Predictive modeling is increasingly including the lab scores. “Increasingly” meaning that instead of 1% of models having lab data, maybe 3% do. Still, it’s a start. Lab values allow actual prediction, instead of simply drawing a line connecting last year’s high claims to this year’s high risk scores;

(3) The cost of interventions is declining quite rapidly, largely with the advent of mHealth (use of mobile communications devices in health care), which is hugely overrated by venture capitalists as a vehicle for getting rich from, but quite appropriately rated as a way to facilitate contact with members if indeed privacy regulations get rewritten to assume that the only person who answers a cellphone is the owner of that phone, and hence no “opt-in” app is needed;

(4) Some physicians are getting involved because their contractual arrangements and accreditation, such as patient-centered medical homes, are requiring it;

(5) And finally, my own forthcoming book, Why Nobody Believes the Numbers: Separating Fact from Fiction in Population Health Management, will take care of the last item. Imagine the Outcomes Fairy-meets-The Hurt Locker. Credibility will be restored for those vendors whose outcomes are modest but valid. The introduction may be downloaded gratis from www.dismgmt.com .

Is disease management dead? No. It is going through a transition period in which older models are being replaced via “creative destruction” and plain old innovation with newer models. This isn’t too much fun now but ultimately this trial-and-error process should create health-improving interventions that are truly effective in preventing, forestalling and addressing some small but significant portion of the 75% of cost attributable to people with chronic disease.

So I think perhaps these two seemingly conflicting posts are in broad agreement, the only difference being that what I believe is well-founded, evidence-based optimism that the industry can innovate its way out of the current stagnation. On this point, only time will tell. In a few years we should know, to quote the immortal words of that aforementioned great philosopher Rick Perry, whether or not who is right.

17 replies »

  1. The problem is with the economics of commercial disease management services! They get paid by third party payers to do “feel good” monitoring of patients with phone calls, physiologic data, etc., then hand the problem patients to the doctor and expect the latter to fix the problem for free. Such disconnect is what hampers disease management services.

    When providers with prescriptive authority start getting paid for asynchronious monitoring of patients between face-to-face visits, the return on investments by third party payers will be realized by way of better outcomes and reduced hospitalizations. There are already payment models in existence that pay physicians for reading reports without a face-to-face encounter, e.g., radiologists and pathologists. The inclusion of primary care physicians getting paid for reviewing remotely gathered physiologic data on diabetics, hypertensives, and people with congestive heart failure among other chronic diseases stands to be a game changer for third party payers and patients. I am not sure why the former fail to see this day in and day out.

  2. I completely srpuopt Graham’s wellness orientation toward the future. The single most important mind-shift to live a healthier, happier, more creative and productive life is to be aware and mindful of the effect of one’s current actions on the future. When I do Life Mapping with my client’s, I get them to display the future world they want to live in, and then help them discover ways to begin using their Life Map as a guide to how they live in the present. Without that orientation, our culture generally encourages us to live in the present, which ignores activities with future but little present payoff.

  3. Disease Management has a bad name because some DM companies do a bad job. They attempt to push as many people through a process as possible so they can say they have a huge ‘participation’ in their program. Participation has oh so many definitions…
    Managing a specific disease instead of the risk of the entire population is a waste of resources – the individuals who need management are those who are either not yet ill but have seriously bad lifestyle issues or biometrics or those who are moderately ill but totally non-compliant with all standards of care – those are the ones who need help with coordinating their care. & if Dr below doesn’t read the letters he gets from anyone trying to coordinate care of patients, he is not practicing good medicine – and could be liable for not taking action when notified of a patient on two drugs (which he might not have prescribed) that can have a bad outcome. We all need to be on the same page when the good care of patients is on the line!

  4. I wonder if Al’s assetion is based on failure of some of Healthways program. I wish before we start conjuring the images of consumers, understand their various segments. Edelman conducted one such study.

    One group is obviously poorly engaged consumers. There is obviously savings to be attained by guiding them. But that process of mentoring is nothing but changing people and there are too many entities you are fighting when trying to do that. I have been practicing and assisting people of with meditation and incorporate it’s principles in daily lives. No more than couple in thousand make it part of their daily lives.

    From what I have known about Healthways they set scripted questions to call consumers about and promised high saving per member which may not be realistic.

    I am sure the highly educated doctors in that company and n THCB feel hoi polloi can do better job or be assisted to do a better job. But do they have that authority or charisma that will to sustained change lifestyle of of intended audience? Can we change people?

  5. As a veteran of the disease management industry, and most recently, spending several years assisting provider organizations to manage their patient populations, I fully appreciate the problems inherent in traditional employer-based and health plan-sponsored disease management programs. However, like Al Lewis, I also disagree with the statement that disease management is dead. Although some models have failed in the past, disease management models continue to evolve and are being transformed and incorporated into new physician-led population health models such as the Patient-Centered Medical Home. Further, as health systems assume more financial risk and move towards Accountable Care Organizations, they will take on responsibility for managing entire populations and will be using population health tools and services that evolved from the original disease management principles and fundamentals.

    I emphasized several points that strongly indicate that disease management is alive and well on my blog post here:

  6. We’re getting off topic, and I’m trying to be better about that this year, so I will only point out a couple of things in response.

    First, The consolidation and corporatization you are talking about in the 80s was on the provider and supplier (pharma, devices) side. The payer side corporatization was more a 90s and early 00s phenomenon. I agree that profit maximization on the provider and supplier side, and their exploitation of failed markets (abuse of Medicare rules, drug patents, hospital oligopolies, etc.), have played a major role in the US.

    Second, it isnt that the US pulled away because it increased the rate of health care growth, but because it didn’t moderate that growth as well as other nations. Nations with universal health care. Which we will have in 2014 if the SCOTUS doesn’t get in the way. Universal health care has a way of focusing the mind on costs.

    Our cultural expectations on care (providers and patients) will make cost control harder and more painful, and sadly ideological, here than elsewhere, but the combination of universal HC and a looming debt bomb will make it happen.

  7. Jonathan, I must be missing something here, since to the best of my knowledge, US health care costs have began to diverge sharply upwards from OECD countries precisely in the 80s, at the same time that consolidation and corporatization began in health care, and strangely enough, in close proximity to the DRG introduction. Prior to that we were right there with the rest of the pack.
    Yet we are insisting on doing even more of the same, and on an even grander scale.

    There was indeed a leveling of growth in the 90s if you look at percent GDP, but the actual dollar amounts have been steadily shooting up since 1980. I am not certain that considering fluctuations in GDP is meaningful for cost analysis here, since an excellent GDP artificially flattens the health care graphs, but since those GDPs are no longer distributed as in the 50s or 60s, this is very small comfort for most Americans.

    There may be some things we should go back to.

  8. Margalit, you fail to understand once again that health insurance has always been a low margin business and those cost savings from UM have always been directly reflected in premiums (with a lag of a year or so). George is right that going back to the wild west of indemnity health insurance would be once again the disaster it was before. Costs were going up by sometimes 10% a year in those days (1950s through 1980s) and it was definitely more out of control than the managed care era of the 1990s to now.

    And those were simpler times, when America did not have the specialist-and-bleeding-edge-treatment fever that it has now acquired. Anyway, this is moot. We are not going back.

  9. What a great post. Thank you, Ms. Gur-Arie.

    The CBO report really knocks the administrative/bureaucratic legs out from under the misbegotten PCMH concept. I doubt, though, that the true believers will let this slow them down.

    I also find the conclusion, that disease management efforts failed because of fee for service payments, bizarre. Disease management failed because it doesn’t work.

  10. Perhaps if doctors could keep people out of the hospital with avoidable ailments, the insurance companies wouldn’t need to find more creative ways of doing so.

    Paying the doctors more and letting them practice medicine didn’t work either — that’s why utilization review got invented

  11. Perhaps this CBO report may be helpful to the conversation, although I find the conclusions a bit peculiar. http://cboblog.cbo.gov/?p=3158

    Replacing the intense relationships present in the patient/doctor dyad with an army of account managers harassing patients with phone calls and follow-ups, is not working and it is not going to work. Helping patients afflicted by disease is what medicine is all about. There are no shortcuts, and there will be no shortcuts, until curative remedies are developed.

    Paying doctors bonuses to provide “value” is probably offensive to most doctors, and largely useless. As one physician aptly wrote:
    “We are doing the best we can, given the situation we find ourselves in. If you incentivize us, we will still do the best we can given the situation we find ourselves in. Output change: virtually zero.”

    We need to change the situation, not tinker with kindergarten party favors. Fee for Service is not the problem. More bureaucracy is not the solution. Creating an environment where doctors can practice medicine with the best interest of the one patient in the room as their only concern is what we need to go back to. And sometimes going back to basics is the most innovative thing one can do.

  12. Al,

    Yes, the “disease management” business model is going through creative destruction and will emerge as something else.

    The DM business model died on January 28, 2008

    I wrote in 2010 about why the term “DM” should RIP

    So Dr. G’s pronouncement in 2012 that DM is dead is not exactly news. One would expect that a physician would be more timely in recognizing a patient’s vital signs.

    Many of the underlying principles and economic drivers are sound…stronger than ever. But can we agree to stop calling it “disease management”. How about if we just call it “Al’s latest spiel”? 🙂

  13. “Disease Management” – Is that what those letters are? Those letters from the insurer that say something like, “Your patient has X condition and we noticed they are not on Y drug.” or “Your patient has X condition and guidelines suggest they have Y test.” Those letters? The ones that go straight into the circular file? Guess I’m not very involved.

  14. ” Some physicians are getting involved because their contractual arrangements and accreditation, such as patient-centered medical homes, are requiring it;”


    We’re finding new and more effective ways of making primary care docs work for free.