Most major health-insurance plans offer some type of disease management (DM) programs to their members. Specialty organizations that provide disease management services may contract with health plans to offer these programs. Employers may contract directly with a health management company to offer DM services to their employees, making it more of a benefit option than part of their health insurance plan. DM programs are designed, but not limited to, patients with chronic diseases and conditions such as asthma, heart disease, diabetes, and back and joint pain.
Program Goals
Disease management programs can benefit the patient, employer and health insurance carrier. The goal for the patient is management and understanding of his condition and ensuring he regularly visits his primary-care physician. The goal for the employer is to improve productivity of employees with conditions who miss work due to their condition or their child's condition. For the health insurer, a healthier patient reduces the cost of care; this also benefits the employer by offering lower health care premiums, which ultimately pass through to the patient/employee as well.
Identification Process
Health care and insurance companies that offer disease management programs have several different methods for referral into the DM programs. First, participants can self-refer into the program. If they've received marketing materials or other information from their employer or health plan, they may choose to call for more information. The other primary way to identify participants is to analyze paid medical, pharmacy and behavioral healthcare claims. This process, also called predictive modeling, involves proprietary algorithms where claims data runs through them to identify potential participants. For instance, a health plan member with several visits to the emergency room for asthma attacks and prescriptions for asthma medication is likely to be identified as a candidate for the asthma disease management program.
Program Components
After identifying a patient with a chronic condition, a clinical care manager attempts to speak with her to assess her condition. This assessment traditionally occurs by telephone but may occur face-to-face. The assessment is a series of questions about the patient's current condition, lifestyle and behavioral actions to determine her risk level. Based on the assessment answers, the care manager develops, in conjunction with the patient, a care plan for her to follow. The care manager and patient will have ongoing meetings with frequency determined by risk level --- the more high-risk the patient, the more frequent the discussions. At these sessions, the goal is to educate the patient and improve her health and lifestyle.
Incentives
To encourage participation in DM programs, employers may choose to offer incentives. Incentives for participation or completion of the program are legal, but it's a violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) discrimination rules to tie incentives to any clinical results, according to Business Management Daily. Typical incentive rewards include reduced insurance premiums, a higher level of benefits such as reduced deductible and copays, reduced or free medical supplies, deposit into a health reimbursement or savings account, and monetary rewards or gift cards for health-related stores or activities.
Success Measures
To determine if a disease management program is working, there are a number of measures taken, according to the Care Continuum Alliance. Clinical indicator measurements are taken at the start of the patient's disease management experience and measured throughout the cycle of the program. These clinical outcomes, such as measuring the glycated hemoglobin (hemoglobin HbA1c) test results of a diabetic, are obtained to measure health improvement. A better outcome after completion of the program equals program success. Other measures include patient satisfaction survey results, process outcomes such as reduction in ER visits, and improvement in the patient's quality of life.
