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Should Health Insurer Coverage Be Conditional On Participation In Disease Management?

Posted Jan 03 2012 7:03pm
Standing between patients
and outcomes?
The unsophisticated Disease Management Care Blog used to think the answer was a simple yes. 

Its rationale was twofold
1. The patient impact of the medical and pharmacy benefit, i.e., medications and other treatments, will be greater if there's a link to concurrent care management services that promote self care and increase doctor-patient engagement, and

2. The gateway to accessing the medications and treatments could be used to incent enrollment in care management programs which, depending on the circumstances, increase quality and lower costs .

Both factors undoubtedly underlie the decision of many insurers to combine disease management and coverage of certain services.  For example
Many Medicaid programs won't cover tobacco cessation medications unless the patient is participating in " counseling services ."  That's because much of the original research on the drugs showed they work if they are linked to concurrent behavioral support .  By the way, the same is true when it comes to drugs for the treatment of obesity ( page 53 ), which showed up in this coverage document .

In addition, consider the example of " external insulin pumps ."  These are battery powered, small and discreetly wearable devices that provide a highly tailored course of insulin to persons with diabetes.  They are are also complex and expensive, which is why many commercial health insurers rely on guidelines that require participation in a diabetes program before they'll be approved.

There are exceptions to the rule.  For example, while asthma treatment guidelines ( page 60 ) recommend 'instruction, demonstrations and frequent reviews' along with the prescription of peak flow meters, coverage of these devices is not conditional on participation in an education program.

Upon further reflection, however, it occurred to the DMCB that having to enroll in disease management - whatever its merits - could be viewed by patients as a barrier which could, in turn, paradoxically reduce medication possession ratios , participation in tobacco cessation programs or use of insulin pumps.

In mulling this over, the DMCB turned to the topic of Value Based Insurance Designs. While VBID can be defined as the explicit setting of patient out-of-pocket-cost (such as co-pays or co-insurance) to the underlying value of any medical service,the DMCB thinks it can be broadened to include the removal of any barriers that stand between the patient and high value services.  The highly regarded University of Michigan's Center for Value-Based Insurance Design, in this excellent review , doesn't think of disease management as a barrier but as an incentive.

Incentive or not, the good news is that it's possible to combine VBID and disease management that together achieve outcomes that are better than either one alone .  Unfortunately, the DMCB fears those outcomes are limited to patients willing to enter the programs in the first place: there may be a larger unseen population outside the disease management intervention who aren't included because they don't want the hassle.  In other words, good outcomes for a few known participants doesn't make up for the potentially bad outcomes for the many non-participants.

If any readers have an answer, the DMCB would appreciate hearing from you.  In the meantime, the DMCB cautions that the population health management suppliers need to be aware of the downsides of linking insurance coverage to their services.  They also need to do everything they can to avoid being viewed by patients as a barrier.

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