American College of Physicians: Internal Medicine — Doctors for Adults ®

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Boom times for disease management
leave doctors wanting more control

From the October 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

William A. Fawcett IV, MD, had no idea that a local health plan had hired a disease management firm to manage members with certain chronic illnesses. But then the Beaumont, Texas, allergist-immunologist started hearing from patients who had received phone calls from the company.

The mother of one of his pediatric asthma patients told him that a disease management firm had sent her a peak flow meter, something Dr. Fawcett said was inappropriate because of the child's age. A case manager later told the mother that an albuterol inhaler should be a standard part of her child's treatment, even though Dr. Fawcett had advised against using albuterol regularly. Neither the disease management firm nor the health plan ever told him that his patients were being contacted.

"Fortunately, the mother knew enough from our own educational program to realize the conflict and call our office," Dr. Fawcett recalled. "This was clearly a case where the company crossed the line."

Dr. Fawcett's experience is an example of what can go wrong with disease management programs. While most physicians embrace the theory behind disease management--closely managing patients to keep them healthy and control costs--many say that insurer-sponsored programs add to their paperwork without improving outcomes. Increasingly, physicians complain, disease management is complicating, not streamlining, patient care.

Even as more and more health plans turn to disease management vendors to cut costs, however, some solutions to those problems may be on the horizon. States like California, for example, are considering legislation that would give physicians some control over disease management. And a small number of physicians are trying to reclaim some influence over disease management through high-tech approaches.

Little clinical value?

When disease management was first launched a decade ago as an adjunct to managed care, doctors recognized its potential to improve care by bringing together components like practice guidelines, multidisciplinary care teams and psychosocial support programs. Physicians created their own programs in integrated delivery systems, academic health centers, hospitals and medical groups nationwide.

Lately, though, as employers and accrediting agencies like the National Committee for Quality Assurance have pressured health plans to incorporate disease management strategies, physician programs have been eclipsed by those created by health plans or outsourced to vendors. The Disease Management Association of America (DMAA), a national trade group, estimates that there are 165 disease management firms contracting with health plans.

Analysts say that health plans and vendors are trying to fill a vacuum in the care of chronic patients. "The management of chronic disease is very poor in this country and there is a tremendous need for improvement," said Molly Joel Coye, FACP, senior fellow at the Institute for the Future in Menlo Park, Calif.

Many physicians, however, question the clinical value of health plans' efforts. Chicago internist Daniel H. Litoff, ACP-ASIM Member, said his desk is constantly littered with disease management authorization slips he has to sign that do not spell out how plans or vendors intend to manage patients. Different plans have their own disease management programs, leaving his three-physician Harbor Medical Group trying to juggle a patchwork of different protocols. And all too often, he said, the health plan's idea of disease management is to send patients an occasional brochure that many don't bother to read.

To be fair, not everyone has problems with these programs. Miami nephrologist Carl S. Goldsand, ACP- ASIM Member, has several dozen patients with end stage renal disease enrolled in a program run by a vendor that contracts with Humana Inc. When the program began three years ago, Dr. Goldsand admitted, he was suspicious of what he called the health plan's "hired guns." Today, however, he has nothing but praise for the partnership.

The vendor hired nurse coordinators to contact high-risk patients on a daily basis. The nurses coordinate the efforts of a team that includes wound-care nurses, dietitians, dialysis center workers and transportation providers. They also work closely with physicians to identify and administer treatment plans. "We have fewer hospital days and better blood counts, referrals are much faster and patients are very much in favor of it," Dr. Goldsand said. "It's definitely made our lives easier."

The program has also given his patients resources that Dr. Goldsand and the two other nephrologists at Greater Miami Nephrology Associates could not begin to provide. "How could I afford to do my own disease management program for end stage renal disease?" he asked. "It's enough for our staff to deal with all the different insurers for payment. To deal with patients on a social basis and to track them daily would be impossible."

But many physicians say that they have not enjoyed that type of relationship with programs sponsored by health plans. Some say that programs can even create problems between physicians, straining the relationship between primary care physicians and subspecialists.

David L. Fried, ACP-ASIM Member, one of 60 primary care physicians with Rhode Island's Coastal Medical Inc., recalled a conflict with a disease management program that assigned a cardiology practice to manage one of his congestive heart failure patients. When Dr. Fried realized that the practice had also begun coordinating the patient's smoking cessation program, he asked to have the patient returned to his care.

"If a primary care doctor has a comfort zone managing certain chronic illnesses, then he should do it. I'm very comfortable treating patients with congestive heart failure," Dr. Fried said, adding that he would want a patient with an arrhythmic disorder to be managed by a cardiologist. "I think disease management is appropriate and helpful, but who does it is a good question. Is an endocrinologist the only one who can manage diabetes? Is a cardiologist the only one who can manage congestive heart failure? I'd say absolutely not."

Disease management vendors insist that they are not trying to second-guess physicians or undermine primary care. Without physician buy-in, they say, patient compliance suffers and health plans lose interest in their programs.

"Reputable disease management companies prefer to notify physicians before talking to patients and get physicians to buy into the program," said Al Lewis, president of the DMAA. The problem is that competition among vendors is fierce. Disease management firms are now so "hungry," said Mr. Lewis, that as many as 20% of them might go ahead and contact patients, even if the treating physicians weren't interested in having their patients enrolled. The reality is that in a race for market share and profits, some firms may continue to rely on the kind of tactics that Dr. Fawcett in Texas found so disturbing.

Solutions at the state level

The rapid growth of the disease management industry has not gone unnoticed, and several states are working on solutions to return some control to physicians.

In California, for example, proposed legislation would require health plans and disease management vendors to notify physicians when they contact patients or send them educational materials. (At press time, the legislation was expected to be passed.) The legislation has two goals: to ensure that physicians aren't left in the dark when health plans or disease management firms begin enrolling patients, and to stop physicians from being inundated by authorization forms as health plans and disease management firms try to get programs off the ground.

The legislation would require physicians to authorize treatment decisions, such as the use of durable equipment or the adjustment of medications. As a result, it would outlaw the kind of practices Dr. Fawcett encountered in Texas. Other states are expected to watch the new law closely.

In Virginia, the state department of health recently implemented a disease management program in fee-for-service Medicaid that puts doctors in the driver's seat. Two programs that target asthma and heart failure are run by physicians and pharmacists.

While Louis F. Rossiter, PhD, deputy secretary for operations of the Virginia Department of Health and Human Services, admitted that the programs are more like enhanced drug utilization review programs than comprehensive disease management, he noted that physicians are paid for their efforts. In the asthma program, physicians receive $3 per month for each patient enrolled.

Dr. Rossiter said that as the state offers programs for high-cost, low-frequency diseases like hemophilia and sickle cell anemia, it will likely contract with disease management vendors. But he said the current physician-driven model is a success in asthma management, saving the state $3 for every dollar it spends on the program.

The program is significant because it makes Virginia the first state to implement disease management in fee-for-service Medicaid. While several other states use similar programs in managed care Medicaid, the market for fee-for-service Medicaid--and Medicare--is wide open.

Help from technology

While some states are looking at ways to give physicians a greater role in disease management, physicians themselves are also searching for new ways to take charge of disease management initiatives. Advocate Health Care in Chicago, for example, which already has several disease management programs for the 2,500 employed and affiliated physicians in its independent physician association (IPA), is now working to develop a private Internet network to manage lipids online.

Advocate internist Bruce S. Bernheim, ACP-ASIM Member, said that online disease management programs allow the IPA's physicians to quickly identify and track chronic care patients. Analysts expect that the Internet will allow physicians to more successfully pool disease management resources.

Other groups are reporting success with devices that use Internet technology to monitor chronic conditions. This year, for instance, the Mercy Heart Institute, part of the six-hospital Mercy Health Care system in Sacramento, Calif., began incorporating a device called the Health Buddy in its cardiovascular disease management program. Patients with congestive heart failure transmit information daily to their physicians over the Internet.

"This is definitely where chronic care is going," said Richard R. Miller, FACP, the institute's medical director. "Whether it's interactive television or Internet technology like Health Buddy, technology will dramatically change how we take care of patients."

Dr. Miller said that patients appreciate the daily oversight. He also said that the device has allowed Mercy to double the number of cases it can manage--and to offer its cardiovascular disease management program to physicians outside the Mercy system. Analysts say that such devices will help physicians form the kind of virtual alliances they need to bring more standardization and control to disease management programs.

Technology, however, will give physicians only limited help as they struggle to regain some control over disease management. "Technology is only part of the answer," said Thomas Bodenheimer, ACP-ASIM Member, a practicing internist and clinical professor of family and community medicine at the University of California, San Francisco. "It won't work if you don't offload some of the work from physicians and if you don't have that person-to-person contact that really inspires patients to change their lives."

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