1© www.bhtinfo.com
Chronic Disease Management Megatrends
August 2007
Vince Kuraitis JD, MBA
Better Health Technologies, LLCwww.e-CareManagement.com blog (208) 395-1197
2© www.bhtinfo.com
9 Chronic Disease Management Megatrends
MAGNITUDE: We are just scratching the surface of chronic disease challenges.
INTEGRATION: The 50 year tide is shifting toward integration, away from specialization.
MEDICARE: Medicare has endorsed the need for chronic disease management, but don’t assume that Medicare Health Support (MHS) is the final answer.
PROVIDERS: Care providers are waking up to DM opportunities and threats.
MAKE, ASSEMBLE, BUY? Fewer are buying as health management becomes increasingly strategic.
TECHNOLOGY: DM in your home and your pocket. BEHAVIOR CHANGE: DM is moving from a medical to a
social model; behavior change has become the Holy Grail. CLINICAL AND ECONOMIC ROI: Round one is over, DM
wins; Round 2 has just begun. WILDCARDS!
3© www.bhtinfo.com
MAGNITUDE: We are just scratching the surface of
chronic disease challenges.
4© www.bhtinfo.com
The Big Picture
Partnership for SolutionsPartnership for Solutions
Changing NeedsChanging Needs
1900-1950 Infectious Diseases
1950-2000 Episodic Care
2000-2050 Chronic Care
The $30 Billion Potential DM Market is Barely Penetrated
Disease Management Market Penetration(millions)
$0$5,000
$10,000$15,000$20,000$25,000$30,000$35,000$40,000
Available Market Industry Revenues
Medicaid Market Opens with FL
Healthplans and Self Funded Employers
FEHBP Plans Start Adding DM
CCIP Phase 1
CCIP Expansion
Source: Chris Selecky, President of DMAA and Chair, Lifemasters, 2005
Available Market based on Wachovia Capital Markets Formula
7© www.bhtinfo.com
INTEGRATION: The 50 year tide is shifting toward integration, away from
specialization.
8© www.bhtinfo.com
To Date DM Clinical/Business Models Have Emphasized Specialization
• Specialized companies providing services• Specialized contracting/financing model -- guaranteed savings• Specialized focus on individual diseases (migrating toward
multiple comorbid conditions)• Specialized technologies: predictive modeling, call centers,
medical management workflow software, etc.• Specialized delivery models are developing for unique customers
– Managed Care Organizations• HMOs• PPOs• other
– Medicaid (in various flavors)
– Medicare
– Employers
– Special Needs Plans– Specialty pharma– State high-risk pools– Multiple diseases– Comorbid patients– Highest cost/risk patients– etc., etc.
9© www.bhtinfo.com
The Tide is Shifting:Value Creation Opportunities in Integration
10© www.bhtinfo.com
11© www.bhtinfo.com
MEDICARE: Medicare has endorsed the need for chronic
disease management, but don’t assume that Medicare Health
Support (MHS) is the final answer.
The Event-of-the-Decade for DM
12
© www.bhtinfo.com
Medicare Understands the Problem:Chronic = Disproportionately Expensive
Source: Johns Hopkins, Partnership for Solutions, 2004
13© www.bhtinfo.com
Medicare DM Demos: Virtually No Evidence of Success
• Medicare Health Support appeared to be the favorite son demo to expand DM into Medicare– MHS has attracted worldwide attention
– Legislation requires roll out if successful
• Elements of MHS model– Focus on highest cost/risk population (frail elderly)
– Disease management -- carve out to private companies & health plans ( vs. CCM)
– Guaranteed 5% savings business model
– Short term ROI
– Randomized control trial
• Results to-date: virtually no evidence of success. See http://e-caremanagement.com/first-official-report-on-medicare-health-support-dm-pilot-finds-virtually-no-evidence-of-success/
14
© www.bhtinfo.com
Early MHS Results Are Not Encouraging
• First, although the intervention and comparison groups are similar at randomization, our analyses reveal that an unexpected pattern in PBPM differences between intervention and comparison groups emerges between the time of randomization and the start of the MHS pilots.
• Second, participating beneficiaries tend to be a healthier and less costly subset of the intervention group. Thus, high participation rates will likely be a factor in the ability of the MHSOs to impact their assigned intervention populations. And,
• Third, fees paid to date far exceed any savings produced. The negotiated MHSO monthly fees are a much higher percentage of the comparison groups’ PBPMs than the percentage savings on payments through the first 6-month pilot period. Fees negotiated by the MHSOs with CMS have not been covered by reductions in Medicare expenditures, let alone an additional 5% savings in Medicare payments. Without a substantial reduction in each MHSO’s monthly fee, budget neutrality after the first year is questionable.
• Source: RTI International Report to Congress: Evaluation of Phase I of Medicare Health Support (Formerly Voluntary Chronic Care Improvement) Pilot Program Under Traditional Fee-for-Service Medicare, June 2007
15
© www.bhtinfo.com
Findings from Four Demonstrations
• No effects on adherence or self-care• Only 3 of the 20 programs reduced hospitalizations
or gross costs (4.5% reduction in MCC admissions)– Another had effects for CHF subgroup in urban counties
• No effects on mortality• Scattered modest effects on quality indicators:
– CHF: MCC reduced preventable hospitalizations– Diabetes: Telemedicine improved HbA1c, cholesterol, blood
pressure; MCC reduced preventable hospitalizations
• Patients love the programs
Does Disease Management/Care Coordination Work for Medicare?Does Disease Management/Care Coordination Work for Medicare?
Randall BrownArnold Chen
Deborah PeikesJennifer Schore
Dominick EspositoPresented at Academy Health Research
Meeting, June 2007
Randall BrownArnold Chen
Deborah PeikesJennifer Schore
Dominick EspositoPresented at Academy Health Research
Meeting, June 2007
16
© www.bhtinfo.com
Why Doesn’t DM Work Better?
• Changing patient and provider behavior is HARD:– Limited use of behavior change models– No incentive for physicians to communicate
• Some patients too ill, others not at short-run risk:– But targeting is not the major problem
• Programs don’t collect timely hospitalization and Rx info
• Usual care providers are minimally engaged
Does Disease Management/Care Coordination Work for Medicare?Does Disease Management/Care Coordination Work for Medicare?
Randall BrownArnold Chen
Deborah PeikesJennifer Schore
Dominick EspositoPresented at Academy Health Research
Meeting, June 2007
Randall BrownArnold Chen
Deborah PeikesJennifer Schore
Dominick EspositoPresented at Academy Health Research
Meeting, June 2007
17
© www.bhtinfo.com
Why Doesn’t DM Work Better?
• Programs led by marketers, not clinical experts:– Ineffective use of available data – Unfamiliar with unique needs of the elderly
• Contact info poor in population-based models • Improvements in quality of care don’t guarantee
better patient outcomes in short run
Does Disease Management/Care Coordination Work for Medicare?Does Disease Management/Care Coordination Work for Medicare?
Randall BrownArnold Chen
Deborah PeikesJennifer Schore
Dominick EspositoPresented at Academy Health Research
Meeting, June 2007
Randall BrownArnold Chen
Deborah PeikesJennifer Schore
Dominick EspositoPresented at Academy Health Research
Meeting, June 2007
18© www.bhtinfo.com
Many Other CMS Demo/Pilot Projects Involve Patients With Chronic Diseases
• Medicare is undertaking a wide range of demonstration/pilot projects
• Many directly involve patients with chronic conditions– Physician Group Practice (PGP) – Care Management for High Cost Beneficiaries (CMHCB) – Special Needs Plans (SNP)– Medicare Medical Home demonstration (discussed later)– and others
19© www.bhtinfo.com
Beyond MHS – Testing Different DM Models in Medicare
• Beyond: focus on highest cost/risk population (frail elderly)– Prevention– Mainstream Medicare
• Beyond: carve out to private companies & health plans – Chronic Care Model
• Beyond: guaranteed 5% savings business model– P4P– Shared savings– Fee for service
• Beyond: short term ROI – Long term ROI– Long term quality improvement & compression of morbidity
• Randomized control trial– Observational studies– Rapid learning models
20© www.bhtinfo.com
PROVIDERS: Care providers are waking up to DM
opportunities and threats.
21© www.bhtinfo.com
Model #1: Disease Management Model• Medium sized, privately & publicly held companies• $1.6 billion revenues in 2006 • Payers are increasingly assembling DM components• Key elements
– Telephonic services, centralized call centers• Support patient life style change• Promote evidence based practice
– Started as carve-out model– Guaranteed savings promoted by DMPC– Focusing on highest cost, highest risk patients
• Challenges: physician buy-in, proprietary IT• Major players:
22© www.bhtinfo.com
Model #2: Chronic Care Model
• Pioneered at Group Health Cooperative• Key elements
– Community based– Transformation of health care– Restructuring of physician practice
• Challenges: no reimbursement, academic/research focus
• Protagonists:
23© www.bhtinfo.com
Who Wrote This Statement?
“The literature has correctly indicated that the term ‘care coordination’, which is often used interchangeably with the term ‘care management,’ refers to a variety of activities. – managing the transition of care across settings– use of patient registries to allow for population-based
care protocols, the – use of frequent follow-up with patients to promote
treatment plan compliance and to obtain healthcare data – use of clinical practice guidelines, including feedback to
the physician regarding their degree of compliance with the guidelines
– teaching of disease self-management skills to patients....”
24© www.bhtinfo.com
• Was it written by a DM company? a home health agency? a health plan?
• No, it was written by...doctors!– Source: American College of Physicians Position Paper,
Reform of the Dysfunctional Healthcare Payment and Delivery System, April 2006
• ...and here's the punch line: “These care coordination activities are at the
core of what defines a primary care physician.”
25© www.bhtinfo.com
The Cats are Herding:Medical Home Model Gaining Momentum
27© www.bhtinfo.com
The Medical Home Model –Paying for Technology and Process Improvement
• Proposed payment framework for the Medical Home model includes $$ for:– coordination of care – health information technology – secure e-mail and telephone consultation;– remote monitoring of clinical data using technology.
• Medicare Medical Home Demonstration
28© www.bhtinfo.com
Medicare Medical Home Demonstration (MMHD)
• December 2006 – Congresses passes MMHD• MMHD similarity to MHS: high cost, chronic
patients; multiple comorbidities• MMHD differences from MHS
– No requirement of 5% guaranteed savings– Physicians can keep 80% of savings
29© www.bhtinfo.com
MAKE, ASSEMBLE, BUY? Fewer are buying as health
management becomes increasingly strategic.
30© www.bhtinfo.com
Health Plan Views Of the DM Make/Buy/Assemble Decision Have Evolved
• 5 years ago– "DM is really complicated"– "It will take us 18 months to get started"– "Start up cost are significant“– “Let’s buy”
• Today– "DM isn't rocket science; we've learned from the
vendors"– "Care management is increasingly strategic; it is a core
competency that we need to do ourselves"– "We'll get better integration if we do it ourselves;
medical management workflow software is key”– “We need to assemble DM components and make sure
that we keep control over key leverage points”
31© www.bhtinfo.com
33© www.bhtinfo.com
TECHNOLOGY: DM in your home and your pocket.
Health care anywhere.
34© www.bhtinfo.com
How Purchasers View the Health Care System
35© www.bhtinfo.com
Tech Trends
A. Technology Convergence
B. 2008 Could Be A Breakout Year for Remote Patient Monitoring
C. Platforms For Interoperability & Transportability• Personal Health Records (PHRs)• Google Health• Continuity Of Care Record Standard• Mobile/wireless apps• Hospital At Home
D. Next Generation Technology – “You Ain’t Seen Nothing Yet”
36© www.bhtinfo.com
A) Technology Convergence
CONSUMER TECH
INFRASTRUCTURE
Internet
Smart houses
Personal communications devices -- PDAs, cell phones, etc.
Broadband -- cable, DSL, satellite
Digital cameras, video
Wireless -- 802.11, Bluetooth, RFID, etc.
Voice recognition
etc.
eHEALTH APPLICATIONS Electronic Health Records (EHRs)
Personal Health Records (PHRs)
Remote patient monitoring
Fitness/wellness/prevention
Self care support
Physician/patient secure messaging
Home telehealth/telecare
Decision support systems
e-Prescribing
e-Disease Management
e-Clinical Trials
Predictive modeling
Computerized Physician Order Entry
Quality evaluation web sites
Patient reminder systems
etc.
37© www.bhtinfo.com
Focal Points for ConvergenceHome Networks, Smart Phones, EHRs
PHR/EHRSmart
Phone
HomeNetwork
CONSUMER eHEALTH
Role of IT in Disease Management
Patient Facing
DM Provider Facing
Patient-provider communication tools (IVR, email)
MonitorEngage Intervene
Educate, Coordinate, TreatIdentify, Validate, Stratify, Enroll
Call center
Personal Health Record
Predictive modeling
Remote monitoring (biometric, tele-monitoring)
Personal assessment tools
(HRA)
Educational tools (websites, audio library)
Electronic Medical Record
Decision support tools (CDSS)
Outcomes, Feedback, Follow-up
Clinical integration tools
Disease registry
39© www.bhtinfo.com
B) 2008 Could Be A Breakthrough Year For RPM
• Continua begins to address major challenges– Interoperability of devices– Pricing (indirectly)
• But other challenges remain– IT/integration– Reimbursement/business model– Licensure/regulatory issues
40
© www.bhtinfo.com
41
© www.bhtinfo.com
...but Consider the Systemic Barriers
• Reimbursement• HIPAA: Privacy/confidentiality issues• Physician workflow• Technology maturity
– Infrastructure– Bandwidth– Interoperability/Standards– Friendly user interfaces
42
© www.bhtinfo.com
C) Platforms for Interoperability & Transportability
• Personal Health Records• Google Health• Continuity of Care Record• Mobile/Wireless Applications• Hospital at Home
43© www.bhtinfo.com
D) The Next Generation of DM TechnologyWhen the Technology is Just “There”
“Ubiquitous Health”
“Sense and Simplicity”
“Pervasive Computing”
44© www.bhtinfo.com
BEHAVIOR CHANGE: DM is moving from a medical to a
social model; behavior change has become the Holy Grail.
The Holy Grail: Changing behavior to prevent disease
Behavioral Risk Factors
ChronicCHF
Clinical Risk Factors
Our Future1994-98 1998-2002 Current
Interactive Data Systems
• All of the above plus more real time two way remote interaction between pts., disease managers, and MDs (e.g. interactive TV, implantable devices, PDAs, cell phones, other wireless technologies)
Copyright © LifeMasters Supported SelfCare Inc. 2004 All Rights Reserved.
46© www.bhtinfo.com
CLINICAL AND ECONOMIC ROI: Round one is over, DM wins;
Round 2 has just begun.
47© www.bhtinfo.com
The DM/ROI Debate Of the Past 10 Years Has Not Always Been Framed Constructively
“DM has ROI”
“No it doesn’t”
“Yes it does”
“No it doesn’t”
“Jane, you ignorant slut”
48© www.bhtinfo.com
Reframing the DM/ROI Debate:2 Seemingly Contradictory Statements
#1: Whether DM provides ROI has become irrelevant
#2: The DM/ROI debate will continue to be scientifically evaluated for the next decade
49© www.bhtinfo.com
#1: The DM/ROI Debate Has Become Irrelevant DM Has Gone Mainstream
50© www.bhtinfo.com
#2: The DM/ROI Debate Will Continue To Be Scientifically Evaluated For The Next Decade
• #1 = DM today• #2 = Continuing DM ROI and outcome measurement for the
future
No evidence
Preponderanceof
Evidence
Beyond AReasonable
Doubt
Clear andConvincingEvidence
AbsoluteCertainty
0 100
Level of Proof
•Source: With attribution to Gordon Norman, MD, MBA, Chief Medical Officer of Alere
#1 #2
51© www.bhtinfo.com
WILDCARDS!
52© www.bhtinfo.com
Watchful Waiting....
• Will employers stay the course in supporting DM?• Payers (health plans, employers, government) are
placing heavy bets on personal health records (PHRs). Will they pay off?
• Can pay-for-performance P4P initiatives align incentives?
• Can U.S. style DM be exported to international markets?
• Will Consumer Driven Health Plans (CDHPs) be the spark to ignite a consumer model of chronic disease management?
53© www.bhtinfo.com
APPENDIX ABetter Health
Technologies, LLC
54© www.bhtinfo.com
Better Health Technologies, LLC
• Technology and health care delivery are shifting: – From: Acute and episodic care delivered in hospitals and
doctors’ offices
– To: Chronic disease and condition management delivered in homes, workplaces, and communities
• BHT provides consulting, business development, and speaking services to assist companies in: 1) Understanding the shift 2) Positioning – what’s the right strategy, tactics, and business model? 3) Integrating your offering into the value chain – what are the right partnerships?
• Complimentary enewsletter: www.bhtinfo.com/pastissues.htm
55© www.bhtinfo.com
BHT ClientsPre-IPO CompaniesHealthPostCardiobeat EZWebSensitronLife NavigatorMedical Peace Stress Less DiabetesManager.com CogniMed Caresoft Benchmark Oncology SOS Wireless Click4Care eCare Technologies The Healan GroupFitsenseElite Care Technologies
Established organizationsIntel Digital Health GroupSamsung Electronics, South Korea -- Global Research Group -- Samsung Advanced Institute of Technology -- Digital Solution CenterAmedisysMedtronic -- Neurological Disease Management -- Cardiac Rhythm Patient ManagementSiemens Medical SolutionsPhilips ElectronicsJoslin Diabetes CenterGSKDisease Management Association of America PCS Health SystemsVarian Medical SystemsVRIWashoe Health SystemS2 SystemsCorpHealthPhysician IPACentocor
Top Related