Overcoming resistance to disease management
From the January-February ACP Observer, copyright © 2005 by the American College of Physicians.
By Janet Colwell
SAN FRANCISCO—Internists are keenly interested in finding ways to manage patients with chronic illness more effectively, seeing in disease management the promise of improving care and cutting costs.
But despite the potential for cost savings and better outcomes, such programs are often tough to get off the ground. Physicians worry about having unfamiliar care standards imposed on them, while administrators complain about program costs and staff may refuse to go ahead without electronic medical records.
Yogesh K. Patel, FACP, discusses clinical data from the diabetes disease management program with clerical team leader Shane Lilly. The program, launched two years ago, saw its enrollment jump from 246 patients to more than 8,000.
More than two years ago, Yogesh K. Patel, FACP, faced those hurdles and more when he began chairing a group charged with launching a diabetes disease management program at NorthEast Medical Center in Concord, N.C.
"The biggest obstacle was getting everyone on the same page," said Dr. Patel, a general internist at Copperfield Internal Medicine, one of almost 30 primary and specialty practices in NorthEast's network.
'You have to start looking at your individual group practice as a team effort and expect all staff and administration to share clinical goals and targets, not just financial ones.'
—Yogesh K. Patel, FACP
Now, NorthEast Medical—which has yet to implement electronic medical records—already is seeing major clinical improvements. Enrollment in the program has grown steadily, and physicians are seeing much better disease control as measured by clinical indicators. The program has been so successful, in fact, that NorthEast is preparing to launch similar efforts for patients with heart failure and pediatric asthma.
The key to NorthEast's success was collaboration, said Dr. Patel, who spoke about his experiences at a presentation at the Medical Group Management Association's annual conference last fall. Physicians, administrators and staff must buy into the disease management process and realize they all have a stake in the results.
Said Dr. Patel: "You have to start looking at your individual group practice as a team effort, and expect all staff and administration to share clinical goals and targets, not just financial ones."
In 2001, NorthEast decided to move forward with an ambitious quality improvement effort: expanding a disease management program for its diabetic patients, based on the chronic care model developed at Seattle's MacColl Institute for Healthcare Innovation.
The first step was to establish a 20-member diabetes advisory council composed of community health officials, physicians, nurses, administrators, pharmacists and educators. The council was charged with developing the program's principles, mapping out a multidisciplinary approach and—perhaps most important for physician buy-in—deciding what standards to use for both clinical evidence and data reporting.
"Without standardizing reporting outcomes, you can't compare apples to apples," Dr. Patel said. "Physicians need to know the data are real."
To stimulate further discussion, a strategic planning group filled out an online questionnaire created by the "Improving Chronic Illness Care" program, a chronic care model designed by the Robert Wood Johnson Foundation. The online questionnaire asks participants to rate their institution's chronic care quality in terms of community resources, institutional leadership and support for patient self-management, as well as decision support, delivery system design and clinical information systems.
Working on the questionnaire helped the group identify NorthEast's strengths and weaknesses in chronic care, said Tami Pike, RN, NorthEast's disease management coordinator, in a subsequent interview. "When we found a weak area," she said, "we started brainstorming about what we could do about it." On the plus side, the group realized that NorthEast already had a computerized database with an established diabetic population.
On the minus side, the NorthEast network of 100 physicians and 40 extenders had few incentives for providers to participate in such a program. At the same time, its central database was not connected to its hospital and clinics, making it hard for clinic staff to input data, and the clinic network had no standard process for implementing guidelines and standards.
The next step was to develop a strategic action plan. For tracking purposes, the advisory council decided to zero in on eight quality indicators: hemoglobin A1c, LDL cholesterol and blood pressure levels; frequency of foot (with pulse and monofilaments) and eye exams; and aspirin and ACE inhibitor use. Specific goals were identified for each indicator, based on evidence ranked as either grade A or B in guidelines from the American Diabetes Association. For blood pressure levels, for instance, the group set a goal of assessing 90% of its diabetic patients—and achieving a systolic pressure of below 140 in 70% of those patients, and below 130 in 50% of them. The goals were set with internal benchmarks based on best performance identified by data.
In addition to setting targets, the advisory council also delineated roles for different members of the clinic staff. And before taking the program live, a coordinator met with providers and staff at each clinic, explaining the new program.
How it works
Now when a physician identifies a patient as diabetic, a staff member in the central administrative office travels to that patient's clinic and pulls the patient chart. The staff member fills out a form detailing the patient's medical history over the last 18 months, including blood pressure and hemoglobin A1c levels, lab results, referrals, clinical assessment and related diagnoses.
That information is taken back to the central office and entered into a program database, which generates a patient profile. The physician receives a printout of the profile, fills in updated information at each patient visit and sends updated data to be entered in the central database. In the office, the patient profile, which includes clinical indicators, also serves as a checklist for the physician to review at each visit.
Having that checklist allows physicians to do a more thorough evaluation. "You might forget one of the 15 things you're supposed to check when you see a diabetic patient," said Dr. Patel. "Now, if something needs to be done every 90 days or every 180 days, it's already built into the program."
NorthEast has also implemented other program components to help diabetic patients self-manage their disease between visits, said Dr. Patel. The center has launched pharmacist-directed clinics and group classes that feature registered dieticians and certified diabetic educators.
Approved program protocols also allow clinic nurses to vaccinate diabetic patients according to a "needs" list, give foot exams, schedule eye checks and order labs. The advisory council is also considering ways to get nurses involved in telemanagement. And NorthEast Medical is in the process of implementing a Web-based system to allow clinic staff to enter data, a project funded with help from The Duke Endowment.
Obviously, all of this requires staff time and resources that may not be available in a small practice, Ms. Pike pointed out. As NorthEast's experience shows, electronic records are not a prerequisite to getting started--but there are some basic requirements, she said, such as a data repository.
Beyond that, practices need to decide up front what data to collect and how those data will be used. She suggested a smaller practice might initially limit itself to creating a physician checklist and patient profile, and tracking patient progress over time in key clinical areas.
NorthEast now reviews its disease management data quarterly with physicians, administrators and management to identify areas that need improvement and single out clinics achieving the best results.
And data may help in negotiating better rates with health plans, something NorthEast might explore down the road, Dr. Patel said. It recently shared its clinical data with one of North Carolina's Medicaid programs--a collaboration that may shed some light on whether disease management programs can lead to Medicaid savings over time. That data-sharing has already made it clear, he added, that there are significant ethnic disparities between diabetic patients who are white and those who are African American.
"Our data suggest that it's not so much an issue of access," he said, "as it is getting patients to control."
According to Dr. Patel, physicians are often the biggest critics of disease management at the beginning. Some worry that a program will be used as a scorecard to punish them if they fail to produce specific results. They are also concerned about how the system will determine care standards and clinical targets, and whether these will fit with the physician's practice philosophy.
Dr. Patel said he and the advisory council worked hard to convince both administrators and physicians that the system would not be punitive. At the same time, administrators--who were inclined to adopt the scorecard mentality—had to be convinced that it was collective, not individual, results that would lead to better care and lower costs over time.
Another factor that spurred physician buy-in was the fact that NorthEast's was a homegrown plan, not one put in place by a health system. "Health plan-directed programs are derived out of necessity to cut short-term costs," Dr. Patel noted. "They tend to bypass the relationship between the health care team and the patients."
Measuring results has also introduced a healthy element of competition among physicians, said Ms. Pike. Administrators once sent out blinded quarterly data on best practices, but recently began attaching the names of individual clinics to results, she said. "That's really made people want to work hard to make sure they're doing what they should be doing," she said.
Perhaps the biggest factor driving acceptance is that the program is producing positive results. Take one key target of achieving hemoglobin A1c levels of less than 7%. Since the program began, the percentage of patients who have reached that goal has grown from 11% to 56%, Ms. Pike said—while enrollment in the program has increased from 246 patients to more than 8,000.
Another objection some physicians voiced when the program began is that they were already following the standard of care and didn't need a formal system, said Dr. Patel. However, many have changed their minds after using a tracking reminder system at appointments.
In fact, most of the network's physicians are now enthusiastic about the program because it allows them to more easily delegate tasks to staff, such as foot exams or referrals for eye checks. And using the checklist makes visits much more efficient as physicians no longer have to dig through thick files to find out when a patient had his last blood test.
"It's brought the physicians a lot of intangible benefits," said Dr. Patel. "If you spend five less minutes going through a chart, that's more time with the patient talking about a plan of care. That's a much more efficient use of our time."
As experts look for ways to reform the nation's health care system, different disease management models are starting to receive more scrutiny. With millions of Americans uninsured-and per capita health care costs the highest in the world-policy-makers are calling for smarter ways to spend money and improve care.
Part of the debate over disease management is whether such programs improve patient outcomes—and keep physicians in a central role in patient care. But another big question concerns the ability of disease management programs to reduce overall health care spending, by paying more for preventive and educational services up front and less for acute care over time.
Last October, the Congressional Budget Office issued a review of disease management programs that target diabetes, congestive heart failure and coronary artery disease. The review concluded that there was insufficient evidence to indicate whether disease management programs could save taxpayer dollars.
That review, however, hasn't stopped the Centers for Medicare and Medicaid Services (CMS) from eagerly pursuing the idea of saving money through disease management. In December, the agency named participants in phase one of its voluntary chronic care improvement program, slated to begin this spring. (A CMS fact sheet is online.)
The initial program will enroll 150,000 to 300,000 traditional fee-for-service Medicare beneficiaries with multiple chronic diseases, including congestive heart failure, complex diabetes and chronic obstructive pulmonary disease. CMS officials hope that a coordinated approach to chronic care will improve patients' overall health while cutting the number of costly hospital stays, emergency room visits and disease complications.
According to the CMS, the initial three-year pilot phase will be continued and expanded if the program results in better outcomes and reduced costs. Cutting costs is a major goal, the CMS has said, citing statistics that congestive heart failure patients, for example, make up only 14% of Medicare beneficiaries but account for 43% of Medicare spending.
Health plan results
And health plans—which have pursued disease management programs for years—also report better outcomes and cost savings. Take Kaiser Permanente, for instance, the California-based HMO that has become the country's biggest private health care provider. With 8.2 million members in nine states and the District of Columbia, Kaiser is large enough to have a significant impact on overall disease trends in key markets—and claims a major factor in its success to date is its chronic disease management.
Diabetes management programs companywide, for instance, resulted in a 119% improvement in controlling patients' cholesterol levels between 1998 and 2003, said Helen Pettay, communications director for Kaiser's Care Management Institute, which is devoted to creating, implementing and assessing the best ways to manage diseases. (More information is available online.)
If such improvements continue over the next six years, the health plan predicts that 4,900 heart attacks or strokes will be prevented. And Kaiser officials estimated that disease management programs in 2003 led to $200 million in savings in its Northern California region alone related to care for patients with heart failure, heart disease, diabetes and asthma.
Individual studies of other plans also point to long-term savings, according to America's Health Insurance Plans, a national trade group with 1,300 member companies. The group's 2003 survey of members with disease management programs found, among other results, that per member per month costs for commercial and Medicare members enrolled in one plan's congestive heart failure program were 33% lower than those in a control group, while another plan's diabetes program posted a 6.4% reduction in total annual costs.
And Nashville-based American Healthways, a private provider of disease management services operating in more than 50 U.S. markets, reported impressive 2002 overall cost savings and quality improvements with a diabetes management program. (The program served more than 20,000 diabetic patients enrolled in four Medicare HMO plans.)
After the program's first year, the company reported a 17.1% drop—or $114 per member per month—in total health costs and an almost 16% decline in hospitalization costs. (The report is online.)
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