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30 Health Care Financing Review 1 (2008-2009)

handle is hein.usfed/hhcrefngrv0030 and id is 1 raw text is: Overview: Disease Management Mary C. Kapp INTRODUCTION Improving health care quality and reduc- ing costs are attractive selling points for disease management (DM) programs. DM is widely used by insurers and employers, with revenues approaching $2 billion a year (Mattke, Seid, and Ma, 2007). The appeal of DM has spread beyond the pri- vate sector and is increasingly being con- sidered, if not adopted, by public payers. The growing chronic disease burden, expanding emphasis on the importance of life-style related conditions such as obesity, and escalating heath care costs present challenges that DM purports to address. There are a wide array of DM programs and specific intervention services, some integrated into care delivery settings and others primarily telephonic. Some DM programs' focus is limited to disease- specific support. Others take a broader, holistic, care management approach. This has enhanced appeal when managing populations with multiple comorbidities. A more recent focus for the industry is pop- ulation health, extending the disease-spe- cific and multiple conditions approaches to incorporate wellness management of entire populations, even those without chronic conditions. There is no single definition of DM's interventions. Interventions are not just program specific, but person specific and also often vary with each contact. Pro- grams may seek to improve adherence to The author is with the Centers for Medicare & Medicaid Ser- vices (CMS). The statements expressed in this article are those of the author and do not necessarily reflect the views or policies of CMS. evidence based prevention and treatment guidelines, working with providers and/ or with patients to improve care. Other general strategies in DM include patient education aimed at improving self care and adherence to treatment plans, and to communicate with health care provid- ers. Some programs include additional supports such as coordinating or provid- ing transportation, medication, or social support services. Similarly, target populations can vary dramatically. Questions remain as to what criteria identify the optimal population to benefit from DM. Is it the highest cost group, a specific set of diagnoses, a particu- lar utilization pattern, or some combination of these factors? Are there other subpopu- lations where the benefit is minimal or non-existent that should be excluded? DM providers working with Medicare popula- tions have remarked on the challenges of multiple comorbidities, especially cogni- tive impairment, and general frailty of the population. That care is delivered by many different providers for conditions that are often long-standing is often in contrast to younger, healthier populations. Overlaying this are the added complexities of other social service needs, low literacy levels, and financial issues. The structure of the public sector pro- grams often differs as well. Issues such as the timeliness of claims or other utili- zation data and the inability for real-time notification of hospital admission may require altering the DM approach. The monthly management fees paid in the Medicare demonstrations reported in HEALTH CARE FINANCING REVIEW/Fall 2008/Volume 30, Number 1 1

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