Disease Management Strategies May Work With MH Care

Small-scale disease management (DM) projects currently being tested by the Centers for Medicare and Medicaid Services (CMS) could serve as a catalyst for more widespread use of DM in the public sector.

While there are unique challenges to making DM work in public programs, the concept holds promise for cost-effective improvement in health outcomes for chronically ill beneficiaries, said Sandra Foote, director of the Health Insurance Reform Project at George Washington University. The project is funded by the Robert Wood Johnson Foundation.

Foote wrote the report “Population-Based Disease Management Under Fee-for-Service Medicare,” which appeared in the July Health Affairs.

She told Psychiatric News that though specific disease management programs for mental illness are not envisioned in the Medicare program, and are relatively uncommon in the private sector, there is a significant opportunity for effective management of chronic mental illness.

Foote cited data from a previous study by the Health Insurance Reform Project showing that mental illness is a major driver of costs among the under-65 population in Medicare. And leaders of DM programs for mental illness that do exist in the private sector and in the Medicaid program say that mental illness fits the model of DM that has proven successful with asthma, diabetes, chronic obstructive pulmonary disease, and other chronic conditions.

Foote observed that the venture into DM marks not only a new direction in the clinical care of public-sector patients, but also in the role of CMS.

Government Role Shifts

Traditionally, that role has been to set fees, pay claims, and administer programs, but with the initiation of DM programs, CMS is making a significant shift toward quality improvement and management of clinical services, she said.

“This is fairly new and is a response to the fact that there are complications and comorbidities associated with chronic disease that can be made less costly and less devastating if they are managed better,” Foote said. “Fragmentation of care and lack of support for patient self-care are major problems in the fee-for-service Medicare program. Physicians typically don’t have timely, accurate, and complete patient information because the care is so fragmented.”

Drug Companies Launched DM

DM was introduced in the early 1990s by pharmaceutical companies as a way to increase patients’ compliance with medication—and, some would say, to increase pharmaceutical sales.

It has since evolved in the private sector into a competitive industry in which private companies contract with health plans to offer comprehensive support services for specific chronic-disease groups. Companies that offer DM are typically paid a fee by a health plan in return for a guarantee of savings.

As Foote noted, DM programs vary widely in the private sector, but they typically offer the following services as part of a hybrid of beneficiary and physician support services: periodic phone calls from program staff, such as registered nurses; personalized goal-oriented feedback on self-care; access to 24-hour nurse call centers; and educational materials by mail, Internet, or video.

Physicians Receive Alerts

Physicians may also receive alerts when patients need medical attention, reminders when preventive services are overdue, and periodic patient-status reports. Some DM programs have expert clinical information systems that integrate evidence-based clinical guidelines with participants’ data from multiple sources, such as claims data and self-reports.

“The key concept is the identification of populations whose outcomes are not good and for whom there is evidence that they are not getting the support they need to better adhere to evidence-based care, including self-care,” Foote told Psychiatric News.

Last year CMS announced a three-year demonstration project for DM of beneficiaries with advanced-stage congestive heart failure, diabetes, or coronary heart disease.

“This demonstration can help us learn how well these programs work and how best to make these services available to Medicare beneficiaries,” said Health and Human Services Secretary Tommy G. Thompson at the time.

Thompson said that studies have shown that a relatively small number of beneficiaries with certain chronic illnesses account for a disproportionate share of Medicare expenditures. Patients with these conditions typically receive fragmented health care across multiple providers and multiple sites of care, and they often require repeated, costly hospitalizations.

The demonstration project was authorized by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA).

Foote noted that in addition to the BIPA projects, there are a number of other “coordinated care” demonstrations authorized by Congress in the Balanced Budget Act of 1997, a capitated DM demonstration recently initiated by the Bush administration, and an end-stage renal disease management demonstration.

“It is a rapidly evolving field,“ Foote said. “People are trying to figure out ways to do DM in the public sector that respond to patient-privacy concerns and that respect the traditional role of the physician.”

But she said the demonstration projects initiated by CMS are probably too small to provide much insight into how well DM would work on a program-wide basis. “Many of them are being tried in settings that would not translate into a scalable model for Medicare to implement nationally,” she said. “What they are doing is testing types of interventions, not a program structure that could be readily scaled up.”

While the opportunities for cost savings and improvement in health outcomes is great, the challenges of introducing DM on wide scale in the Medicare program are significant.

“One major challenge is that the CMS needs to develop the infrastructure to support the real-time use of patient claims data,” Foote said. “In addition, there need to be a lot of policy decisions about where [CMS officials] think they are most likely to have a positive impact. And CMS will have to work very closely with whatever contractors it engages to ensure that DM is executed in a way that is supported by beneficiaries and physicians.”

The patient population in Medicare is likely to present challenges not found in the private sector. “There are 35 million people in the fee-for-service Medicare plan, and the range of problems is very broad,” Foote said. “They will have a lot of problems related to language, education, multiple chronic conditions, and cognitive difficulties.”

Foote also said that mental illness is a critical component in the cost of caring for the Medicare population. Among beneficiaries under age 65, mental illness accounts for 13 percent of their total health care costs. And that segment of the Medicare population is expanding—between 1995 and 1999, enrollment of nonelderly people in Medicare went up by more than 800,000, or more than 18 percent, Foote said.

There is some precedent for offering DM for mental illness in the public sector. Sandeep Wadhwa, M.D., is a geriatrician and vice president for sales and marketing for the McKesson Corporation, a Broomfield, Colo., company specializing in disease management. McKesson has been offering a version of DM for Medicaid patients with depression in Washington, Florida, Mississippi, and Colorado. Though he would not reveal financial data about the company’s performance, he said the programs have been successful in saving state Medicaid dollars.

“These programs are budget neutral for the state,” he told Psychiatric News. “They pay us for administrative services, and we guarantee a savings offset in the form of claims reductions.”

Wadhwa said that the program offers depression screening to Medicaid patients and, on the basis of results, coordinates care with whatever mental health network is in place, or works with the primary care physician to find a “medical home” for the beneficiary.

“A lot of time we are coordinating with the mental health carveout and plugging people into a system they haven’t touched before,” he said. “We think there is a real dimension of social isolation we are addressing through our outreach mechanism, by plugging people back into a support network.”

Foote’s article is posted online at www.healthaffairs.org/WebExclusives/Foote_Web_Excl_073003.htm. ▪