Look at cost, utilization before starting DM program
Use of benchmarks helps ensure accuracy
Before you consider a disease management program for your patient population, look at the costs and whether you will benefit from the investment needed.
Disease management for just a few patients can be costly. You need staff to provide personal intervention with the patients, an electronic medical records system to keep all the information in one place, and a way to give feedback to the primary care physicians.
If physicians are not financially at risk for the patient’s entire health care costs, there may not be a lot of incentive to provide disease management, says Robert Stone, president of Diabetes Treat ment Centers of America in Nashville, TN.
"To make the value equation work, you need to work with the entire cost posture. Health plans and physician groups who have taken risk could develop a partnership so that some benefit flows back to the physician, " Stone says.
If your practice is new at managing risk for patient care, do some research to find out if disease management will work for you. Don’t just rely on information provided by an HMO on the historic needs of your population, asserts Dennis Dunn, PhD, senior scientist and one of the founding members of the Sachs Group, based in Evanston, IL.
"HMOs have been tracking chronic diseases for years and have a good idea of what kind of resources their patients are consuming. But the information is not necessarily available for pro viders who are negotiating to provide health care for the HMO’s covered lives. Anyone contracting with an HMO will need independent benchmarking," he adds.
Limited value
Claims forms have limited value because they often don’t list comorbidities that may be the underlying cause of treatment. For instance, a physician treating a patient for vascular complications may record that code but may not note on the claim that the patient also has diabetes, he says.
So many HMOs are engaged in special contracting that it may be impossible to determine how many individual visits were made for any sort of specialty care, such as radiology.
"If you’re contracting for a capitated contract, it’s critical to know how many visits you have to support. That’s not what a claims database is designed to do, and the information you need is not necessarily available," Dunn says.
It’s good to look to national organizations, such as the American Diabetes Association and the American Heart Association, for good nationwide information on chronic diseases. But don’t forget the peculiarities of your local environment, warns Dunn.
"You need to know if the disease is more prevalent in your area and if utilization patterns can help you determine if your patients will have higher hospitalization or health care usage rates than in other areas," Dunn says.
For instance, in some parts of the country, the average prevalence of diabetes is 2% to 3%, but in others it may be as high as 40% to 50%, Dunn says. "There are characteristics, such as how many times patients use the emergency room, that phy sicians may not have much control over, but they can help determine the amount of resources needed for a group of patients," he adds.
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