Business Week and Disease Management: A Closer Look
Posted Feb 07 2010 2:19pm
The Feb. 4 Business Week has an article on disease management provocatively titled ‘Take Your MedsExercise – and Spend Billions.’ The accompanying graphic displays a circa 1950’s nurse pointing to a Rube Goldberg contraption that ends in cash being shredded. Ouch.
The article opens with a description of General Electric’s disease management (DM) misadventure and contrasts that with the seemingly inexplicable $2.5 billion commitment of 75% of the nation’s large employers to the DM industry. Even more mysterious to authors Chad Terhune and Arlene Weintraub is the success of ‘industry lobbyists’ in convincing the Obama Administration and Congress to include some version of DM in health reform. They credit a vast lobbying operationfanciful marketingexaggerationlack of scrutiny and the dissemination of biased insider studies. And what unfriendly news article on DM would be complete without dredging up the hapless Medicare Health Support study. Alassays the expert-critics that are quoted in this piecetobacco cessation and exercise promotion have no return on investmentit's all wasteit's all money down the drain!
To the reporters’ creditthey did take the time to interview industry veterans who recycle many of the Ver. 1.0 arguments in favor of disease management: 1) the fact that employers and Medicaid programs continue to support the concept year after year cannot be ascribed to naivetythere’s gotta be something to this2) studies in the public domain are old studies with crude methodologies examining relatively primitive programswhile newer studies or newer programs are in-houseinvolve state-of-the-art consumer/physician oureach and not readily available to dubious reportersand 3) enough with Medicare Health Support alreadyit was stillborn thanks to sicker patients tilting the intervention groups and Medicare strangling things by not providing timely information.
The Disease Management Care Blog offers up some additional Ver. 2.0 observations not addressed in Business Week 1. While measures used to gauge DMsuch as claims expense and hospitalizations are relatively crudethe DM industry has only just begun to coalesce around a common assessment methodology. Future reports on DM’s programs will a) hopefully use it and b) submit their findings to peer review. Pending that.....
2. No proof that DM works is not the same as proof that DM doesn’t work. And if the lack of proof is the standard by which we should judge the merits of medical care in generalwhat proof is there that the patient centered medical homepay for performance or the electronic health record really saves money? Or for that matterhas anyone subjected primary care to a prospective randomized clinical trial? Before readers shake their heads at such apostasyconsider an important question: would the introduction of a primary care network into Dade Country result in lower per capita health care costs?
3. While the lack of proof is a result of the lack of positive peer reviewed researchbut maybe it’s peer reviewed research's reliance on randomized clinical trials that is lacking. To quote Don Berwick in JAMA:
'...multicomponent intervention (is) essentially a process of social change. The effectiveness of these systems is sensitive to an array of influences: leadershipchanging environmentsdetails of implementationorganizational historyand much more. In such complex terrainthe RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect.'
4. As for the MHS demothe DMCB doesn't believe any DM results from FFS Medicare is generalizable to the commerical employed populations. It's a different kind of population with a different kind of insurance benefit. What's morethe DMCB thinks it's notoriously difficult to demonstrate any savings in a FFS Medicare setting. Even the allegedly successful Medicare Coordinated Care Demo would have been a complete bust if it weren't for some statistical legerdemain that barely squeezed 1 success out of 15 times at bat. The DMCB thinks that there is too much ‘noise’ in the health care utilization of an elderly 'free-range' population with access to every health care option known to man. Modern clinical trial methodology just may not be up to the task to detect differences in an environment with a relentless 10% trend.
5. Finallythe DMCB says the real value of DM is not necessarily a function of how much it can reduce costs. Ratherits value is based on what offers for the cost. While the Business Week article alleges it adds up to billionsthe cost at an individual level per member per month is comparatively modest and the benefit to the consumer is relatively high. Compared to the majority of high-cost low-value services typically covered by U.S. health insuranceDM is a bargain. The coin of the realm is NOT saving money but giving consumers their money’s worth.