With rising health costs threatening to bankrupt Medicare and Medicaid and place private insurance out of reach for more Americans, disease state management (DSM) has become a beacon of hope. The Centers for Medicare and Medicaid Services (CMS) certainly seems to have become a true believer in its cost-lowering potential. In February, it sent a letter to the states urging them to adopt programs to help those with chronic illnesses better manage their diseases and offering to match state costs of running these programs.

“Disease management is an exciting opportunity to significantly improve the care delivered to Medicaid beneficiaries with chronic conditions,” said Dennis Smith, the then acting administrator of CMS when the letter was sent. “It uses the best of managed care techniques of coordinating care that may not have been available in a fee-for-service delivery system.”

In addition, the Medicare Prescription Drug, Improvement, and Modernization Act passed last year establishes two new programs—the Voluntary Chronic Care Improvement Program and the Care Management Performance pilot program—to further explore the potential of disease management.

This CMS focus on disease management could encourage its greater use and acceptance, as well as provide new opportunities for home health care service and equipment providers that deal with chronic diseases, including those that deal with asthma. However, challenges remain for any home health care provider seeking to offer asthma disease management. For example, Joe Lewarski, president of Hytech Homecare & Hytech Medical Supply in Mentor, Ohio, says that even though his company successfully offered disease management for asthma for 5 years and even published a paper on the program’s outcomes and cost savings (more than $1,000 per patient), interest in it has dropped off markedly among health maintenance organizations (HMOs) in his area.

“I think the large payors we were dealing with went a different direction and decided to look at spending those resources a different way to see if they could get the same return on investment,” Lewarski says. “We know that they haven’t [gotten the same returns], but they haven’t reinvested back in this direction either.”

One of the problems, Lewarski says, is that disease management is still a very young field and it is not a concrete visible product, like a wheelchair or an appendectomy, that payors can point to as the good they get for their money. Disease management programs are individual in nature because they are designed to address individual populations. They therefore do not easily adapt to standardized coding and billing systems with specific payments tied to specific goods.

“We encountered some problems in billing, getting paid, and getting payors to understand what this was,” he says. “It was always an outlier to the payors’ normal processes.”

However, Lewarski has not given up on the promise of asthma disease management. “I still think there is a strong potential for disease management in the future,” he says. “I just think it hasn’t been as well defined. We think home care is underregulated, and this is an area where there is just not a lot of definition and standardization in how you get paid.”

What is Disease Management?
Bob Stone, executive vice president of American Healthways, a disease management company based in Nashville, Tenn, and the immediate past president of the Disease Management Association of America, agrees with Lewarski that part of the problem today is that there is still a fair amount of confusion in the market about what exactly is and is not disease management and what certain services are worth. However, payors are starting to get savvier about what they pay for, Stone says, and that is not always good for companies such as Hytech. According to Stone, many insurers now prefer to purchase disease management on a population basis, as his company offers, and not on a services basis; as a result, many DME companies may now find it harder to get paid for disease management.

“Disease management is a very popular term,” Stone says. “Payors, employers, and now the feds are in the game with lots of money, and understandably everybody would like to be able to get a piece of that money, but not everybody has the capabilities to deliver on the fundamental value proposition for disease management in a way that is economically sound and scalable. I think purchasers are looking more carefully at entities that say they have disease management because they have professionals and know to educate patients. They are not [doing true disease management] and health plans know it and are unwilling to buy it on the service basis. They want to buy it on the population basis.”

To offer comprehensive disease management, a company must provide six things, Stone says. They are:

• population identification processes;
• evidence-based practice guidelines;
• collaborative practice models to include physician and support-service providers;
• patient self-management education;
• process and outcomes measurement, evaluation, and management; and
• routine reporting and feedback.

“If you look at those six things and you look at home health companies, DMEs, and other ancillary health care service providers, you are going to find that they are deficient in one or more of those components,” he says. “A small home health care company can’t provide comprehensive disease management service. They don’t have the infrastructure, they don’t have the platform, and they don’t have the data management capabilities. Disease management services are not about sending a nurse or other professional into the home to work on the patient one by one. That is not a scalable solution. And I would suggest that is why they are having problems getting health plans to pay for it. It is not a model that has demonstrated itself to be effective, and disease management organizations have no problem getting health plans to pay for it. Disease management organizations are taking on entire populations. For our customer Blue Cross in Minnesota, we are managing 110,000 lives.”

Add disease management?
However, not everyone agrees on this definition of disease management. One is Thomas Kallstrom, RRT, FAARC, director of respiratory care services, biometrics, and cardiac rehab at Fairview Hospital in Cleveland, and author of a guide to the disease management of asthma for respiratory therapists that was published by the National Institutes of Health (see below).

“Disease management doesn’t have to be grand scale at all,” Kallstrom says. “I have seen good programs come from small companies as well.”

He advises companies thinking about adding disease management services to do their homework first. “You shouldn’t be doing it just because you think it is a neat thing to do,” he says. “You need to study up and see if there is a need in the first place, and then, the need might not be asthma, it might be COPD or diabetes.”

If you do determine that there is a need, the next step, Kallstrom says, is to ally yourself with an influential person within the medical community, such as a local hospital’s pulmonologist, medical director, or even department head of respiratory care. Also study clinical literature and other disease management program templates to determine what has worked in other situations.

“But then try to make it into your own type of template, because you are not going to be able to borrow entirely what someone else does,” Kallstrom says. “Everything is going to be different in your patient population.”

Finally, you need to measure outcomes. “If you don’t, you are dead in the water as far as showing that you have done anything,” he says.

Lena Lindahl is a former editor of Dealer/ Provider.