"Diesease management" by insurance companies adds no value

[eridani]

http://content.healthaffairs.org/content/29/12/2197.abstract

German Diabetes Management Programs Improve Quality Of Care And Curb Costs
Abstract

This paper reports the results of a large-scale analysis of a nationwide disease management program in Germany for patients with diabetes mellitus. The German program differs markedly from "classic" disease management in the United States. Although it combines important hallmarks of vendor-based disease management and the Chronic Care Model, the German program is based in primary care practices and carried out by physicians, and it draws on their personal relationships with patients to promote adherence to treatment goals and self-management. After four years of follow-up, overall mortality for patients and drug and hospital costs were all significantly lower for patients who participated in the program compared to other insured patients with similar health profiles who were not in the program. These results suggest that the German disease management program is a successful strategy for improving chronic illness care.

From the discussion--

The quest to reorganize care for chronically ill beneficiaries has led to different approaches in the United States and Germany. While US Medicare invested in regional pilots that differ in their structure of care delivery and may use disease management vendors, German health plans decided on an approach with a heavy emphasis on quality assurance and the primary care physician as the program manager. The emphasis is on educating both the patient and the care provider. Characteristics of care considered desirable in a patient-centered medical home, such as coordination, integration, timeliness, efficiency, and effectiveness as well as the
patient-centeredness of care, improved markedly.

Comment by Don McCanne of PNHP: The Germans have demonstrated what disease management should be all about. Using primary care medical homes as a base, the physicians and their in-house teams provided coordinated and integrated care for their diabetic patients with the result that physician-patient relationships were enhanced, costs were lower, major complications were fewer, and mortality was reduced in half compared to the control group.

The phenomenal success was no doubt in a large part due to placement of the disease management process precisely where it belongs - within the team at the patient's own primary care medical home. This is a model based on patient service.

In contrast, the U.S. uses a business model, often with intrusive, fragmented interventions by outside vendors and private insurers. The U.S. model compounds our administrative excesses, fails to recover the additional costs of these outside, for-profit business entities, and yet has not demonstrated the dramatic benefit that this German approach has.

What is our problem here in the United States? Why do we keep insisting that "the market can do it better," whatever that means? It is blatantly obvious that diseases are best managed by the patient's own medical team - a team that is, gee, trained to manage diseases, and a team who knows the patient's medical and cultural background. Yet we passively accept an expensive, intrusive, ineffectual insurance industry and their vendors because, somehow, we are mesmerized by the meme that the market can do it better, as if private practices weren't the health care market that actually matters.

Of course, now the insurers claim that disease management should not be counted as an administrative service, but should be classified as a health care service so that it provides them with a more favorable medical loss ratio. Thus the insurers are claiming, in effect, that they are partially usurping the role of the health care team in providing health care services
themselves, and they are even being paid for it with fees that they explicitly classify as health care expenses under the medical loss ratio.

Haven't we had enough? Let's throw them out and establish our own public national health program that will redirect our funds toward reinforcing our primary care infrastructure so that our physicians and their teams will be there to manage our diseases when we need them managed.

My comment: Is it any wonder that attempts to hold down health care costs by regulating medical loss ratios have utterly failed in 15 states?

[Hannah Bell]

1. yes: "intrusive, fragmented interventions by outside vendors and private insurers"

one of the most horrible developments of my lifetime is seeing aged sick people having to drive all over hell & gone to get treated. one hospital for surgery, a different hospital in a different city for chemo, etc.

all because the suits deem it "efficient". for who, i have no clue; all i can guess is that by fragmenting it & increasing middlemen it expands the total cost of care, which the profiteers deem "efficient" for their bottom line.

[eilen]

2. It certainly isn't efficient.

As a homecare nurse I often had patients with 6-8 different doctors that required phone calls. It would have been much better to deal with one doctor who would lead the team. High blood pressure and wild vacillating blood sugars? I'm calling 4 different doctors. I tried just sending a fax to them but under the current system, that notification (phone call message and fax) alone is not enough, one is required to "follow up." Only one MD actually returned my calls and why? They all have patients to see!

Teaching healthy lifestyle changes and "when to call the doctor" is often the best we can do. Ultimately, the responsibility is the patient. This ends up snowballing to the point where you want to send the pt to the ED (or their Dr. says-- go to the ED) and the pt does not want to. ED care is the most expensive care and often in many cases the ED sends the patient back home with the same problem and we start all over again.

Congestive heart failure with the co morbidity of diabetes type 2 seems to be one of the worst managed health problems we have among our over-50's. They are often on the most medications and have the highest hospitalizations. All it takes is one ham dinner.

[eridani]

6. Hoping you have shared your inside info with your representatives n/t

[eilen]

7. No, the rules we follow are made by Medicare and Medicaid

the rules are designed to extract the most service for the least cost. They retool the assessment tool used (OASIS) as they go along, adding new requirements. The state issues new taxes on the medicaid reimbursement (called a "receipts tax"). The entire system is Byzantine. In the end the agencies either ratchet down their staff and the number of cases they will take and the hospitals limit who they will admit (working in a hospital also opens ones eyes as to the vacillating discharge criteria for patients seems to change depending upon the severity of the bedcrush) ED returns within 24 -48 hours happen with disquieting frequency. There has been an increasing use of the ED overall.

[msongs]

3. US doesn't have health care management, we have profit and loss management nt

[hootinholler]

4. DING DING DING! n/t

[Hannah Bell]

5. +100