Thinking of starting new DM initiatives?
Here's how to select the best ones
If you want to start a disease management program that impacts your managed care organization's (MCO) bottom line in the first fiscal year, you first must identify your highest-cost patients. That may seem like common sense, but too many MCOs jump on the disease management bandwagon without doing their homework, says one expert.
"You have to carefully target your disease management programs in order to ensure a position return on investment. You can't just do disease management for the sake of disease management," says John Byrnes, MD, senior vice president of performance improvement and innovation at St. Francis Health System in Tulsa, OK, who helped Lovelace Health System in Albuquerque develop its Episodes of Care programs.
Byrnes suggests that MCOs use these six criteria to select disease management initiatives:
1. High patient volume. Use your utilization data to identify conditions that result in high patient volume.
2. High-cost disease and chronic conditions. Use claims data to identify patients by diagnosis that account for the highest percentage of your costs.
3. High-risk conditions. "This includes the birth process where the literature shows prevention reduces costs," Byrnes says.
4. High variation in provider practices. Take patient populations with negative financial performance, populations you lose your shirts, like congestive heart failure (CHF), and gather five of your internists in a room. "If you ask them to describe how they treat CHF, and you get five very divergent views, then you have high practice variation."
5. Opportunity for improvement. Examine your current programs and determine whether there are opportunities to reduce costs and improve care.
6. Qualified professional to head the effort. "You must have a major player within the system to drive a disease management initiative," notes Byrnes. "All of these efforts need someone to help move them forward."
When MCOs put all or most of these criteria together, they get a positive return on their investment and show significant returns within the first 12 to 24 months, he says.
"When I charter a new disease management team, I always look for that low-hanging fruit. Those are the easiest areas to improve with the biggest bang for the buck." (For discussion of how to measure the success of your disease management programs, see story, below.)
Once you've identified opportunities for disease management initiatives, don't reinvent the wheel, he adds. "In today's environment, there are so many national guidelines, case studies, templates, and best practices to share, development costs for disease management have dramatically decreased."
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