Disease management: How soon to take the leap?
Fee-for-service hospitals need to get ready now
When Empire Blue Cross and Blue Shield of New York denied reimbursement for Memorial Sloan-Kettering Cancer Center’s innovative and expensive breast transplant research protocol in 1994, project managers at the New York City-based specialty hospital knew they had to take a long, hard look at their costs of doing business.
"We began to realize that we not only didn’t know much about our research or treatment costs, but we really didn’t know our standard of care," says Mary E. Dowling, RN, MSN, director of clinical services in the division of nursing at Memorial.
Knowing they had to take drastic action, project managers began the arduous process of formulating clinical pathways for each of the 90 different types of cancer treated at the hospital and exploring cost-effective ways to manage their population of 13,000 patients.
The approach they settled on was classic disease management: a collaborative effort to care for chronically ill patients involving health care professionals from a variety of disciplines throughout the continuum of care.
In addition to establishing 17 different disease management teams for diseases such as breast cancer, colon cancer, and lung cancer, the hospital implemented a wide-ranging information system, developed in collaboration with Cambridge Technology Partners of Boston, to track patients from their initial diagnosis to either cure or death.
"We knew that we had to be able to capture information on patients as they entered our system, track where they were on our pathways, and evaluate financial and clinical outcomes," says Dowling.
Although disease management has traditionally been the domain of managed care organizations, capitated hospitals, and pharmaceutical companies, more fee-for-service hospitals like Memorial are getting into the act, largely in anticipation of a capitated reimbursement structure, says Michael Rich, MD, coordinator of a congestive heart failure (CHF) disease management program at Barnes Jewish Hospital in St. Louis.
Despite the clinical advantages of the disease management approach to care, one thorny problem has discouraged some hospitals from adopting it, says John C. MacDonald, RN, MS, CPHQ, vice president of clinical services at Physicians Community Health Group in Brentwood, TN. Whereas case management involves cutting the hospital’s costs per case by reducing length of stay and streamlining care delivery, the goal of true disease management is to actually reduce the number of hospital admissions.
"Under a fee-for-service or discounted fee-for-service arrangement, the problem for the hospital is, if you’re never admitted, they make no money," MacDonald says. "Case management is more lucrative for them because if somebody is admitted under a given DRG, their length of stay can be shorter if they’re managed well. But the goal isn’t to keep them out of the hospital to begin with. That’s the Achilles’ heel that makes it difficult for hospitals."
Capitation is headed your way
At Barnes Jewish, Rich was able to sell administrators on the value of disease management for the hospital’s CHF population by stressing the changing nature of health care reimbursement. Although St. Louis remains predominantly fee-for-service, Rich is aware that it probably won’t be for long. "It’s only a matter of time," he says. "And as managed care and particularly capitation become more the way things are done, it will be more in hospitals’ best interest to establish programs like this one. They won’t have to reinvent the wheel to do this and spend their first several years losing money on all these kinds of [chronically ill] patients. Selling disease management to the administration was partly a matter of them recognizing that this is going to be an important thing for the future in order to control costs."
A more immediate incentive was that having an effective disease management program in place for their high-cost Medicare CHF population could help the hospital’s marketing efforts in securing managed care contracts, Rich says. "There are some fairly significant HMOs and managed care groups in this area, and we still have to compete for their patients," he adds. "By saying we have this program in place, the administration could sort of get one up on our competitors."
That approach is already working for Memorial Sloan-Kettering. Although New York in general has lagged behind the rest of the country in managed care penetration, Memorial has attracted contracts with the local Blues as well as with Oxford Health Plan. As a result, the hospital has actually seen an increase in patient flow. "We really anticipated that we would have fewer numbers, but we’re not finding that," Dowling says. What’s happening is that plans are sending patients to Memorial as opposed to other area hospitals that lack Memorial’s disease management resources, Dowling says.
Effective disease management requires not only a strong commitment from administrators, however. It also requires a commitment on the part of health care providers to smooth out coordination across different care settings, says Marjorie Cypress, MS, RN, C-ANP, CDE, nurse practitioner in the diabetes management program at Lovelace Medical Center in Albuquerque, NM, a largely capitated facility. She adds that case management’s focus on critical pathways contains elements of disease management, but that "for full disease state management, you need that transition and connection between inpatient and outpatient services."
Emphasizing outpatient services
Indeed, what lies behind many disease management initiatives is a recognition of the growing importance of outpatient services, particularly under managed care, Cypress contends. "You can’t teach people all the skills they need while they’re in the hospital," she says, particularly at a time when reducing length of stay has become a major priority. "If people are followed on an outpatient basis and learn self-management skills, they should be able to decrease the number of emergency room visits and perhaps even hospitalizations and visits to their doctors," she says.
For example, most management of Lovelace’s diabetes patients occurs in a pharmacy-run outpatient diabetes clinic. "When a patient comes to the acute setting, we’re right in there to work out the transition to outpatient, and to keep them going, recognizing that they need to be followed up this way," says Cypress.
Stressing health education both in the hospital and through its outpatient CHF clinic, Barnes Jewish has cut CHF-related readmissions almost in half and maintained an average length of stay for CHF that’s well below the national average, Rich says. He adds that the hospital’s most successful interventions including instruction on medication use and proper diet have taken place following patients’ discharge from acute care.
"Disease management gives the patient a more intensified approach to their care, where all the available resources that might help them maintain maximum quality of life and keep them out of the hospital are implemented as soon as possible after the patient is admitted," Rich says. "With people who aren’t managed with the disease management approach, all of these same resources are usually still available, but it may take several days before someone thinks of getting the social worker involved to begin discharge planning, for example. That can lead to identification of problems that people were unaware of before and increase length of stay."
[Editor’s note: For more information about hospital-based disease management, contact:
Marjorie Cypress, MS, RN, C-ANP, CDE, nurse practitioner, Lovelace Medical Center, 5400 Gibson Blvd. SE, Albuquerque, NM 87108. Telephone: (505) 262-7455.
Mary E. Dowling, RN, MSN, director of clinical services in the division of nursing at Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021. Telephone: (212) 639-2000.
John C. MacDonald, RN, MS, CPHQ, vice president of clinical services at Physicians Community Health Group, 750 Old Hickory Blvd., Two Brentwood Commons, Suite 275, Brentwood, TN 37027. Telephone: (615) 373-7304.
Michael Rich, MD, congestive heart failure program, Barnes Jewish Hospital, 216 S. Kingshighway Blvd., St. Louis, MO 63110. Telephone: (314) 747-3000.]
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