Stanley Feld M.D.,FACP,MACE
“An ambitious three-year experiment to see whether the Medicare system could prevent expensive hospital visits for people with chronic conditions like congestive heart failure and diabetes has suggested that such an approach may cost more than it saves.”
In our sound bite society this first paragraph can nullify the potential benefits and cost savings of focused factories and chronic disease management. Nothing could be further from the truth.
Social science experiments invariably suffer from design flaws. They are not double blind controlled studies with comparable treatment and placebo groups. This study compounds a potential error when the study centers are not applying comparable treatment protocols. The faulty methodology invariably leads to faulty and erroneous statistical conclusions. The study was intended to show positive results for the hypothesis. The hypothesis to be proven was that disease management decreases the cost of care.
I have stated in the past that the patient must be the driver of the care and the professor of his disease. Nurse driven call centers detached from patients physicians are not going to accomplish the goal of making the patient the “professor of his disease”. The study groups’ nurses call centers do not use similar protocols. The results of all the centers are usually lumped together. Is one center better than the other in reducing the cost of care? Are the patients well educated? Do the educated patients avoid the costly complications of the disease? Is a three year study long enough to determine if diabetes management works? Were the patients who incurred complications of disease the sickest at the onset of the study? Were patients risk weighed so that comparable groups under intensive glucose control were studied and compared to the same patients that had uncontrolled glucose levels? What was the duration of the disease in patients who were the most expensive to treat?
Additional characteristics of the patients need to be compared and separated. All the people in the study were over 65 years old. However, was there a difference in interest to learn among patients? Did this make a difference in complications? What was the compliance rate with intensive treatment? How long did each patient have his Diabetes Mellitus? How effective were patients at in losing weight? How effective were they in exercising? How many became disease management experts?
None of these questions were answered within the study. The data might be present. The conclusion is not correct until the study is done properly.
“The test borrowed a practice long available through private health plans. Nurses periodically place phone calls to patients to check whether they are taking their drugs and seeing the right doctors. The idea is that keeping people healthier can help patients avoid costly complications.”
Private health plans have tried nurse directed help desks in the past. The healthcare insurance companies never made nurses call centers an extension of the physicians care. Nurse's help desks were imposed on the physicians care. This is not my definition of disease management. The patients have to be engaged in self management. They have to be motivated to prevent the complications of their disease. Patients at different stages of their disease are going to have different outcomes. Patients in the later stages of a chronic disease are going to have worse outcomes than patients at the early stage of a chronic disease. Patients with long term diabetes are at greater risk for complication of the disease.
"After paying eight outside companies about $360 million since mid-2005 to try to improve such patients’ health, Medicare is still trying to figure out whether the companies were able to keep people healthier. But the preliminary data indicate that the government is unlikely to save money."
There is not a single physicians practice in the group report nor a single physician involved in the study design. The healthcare industry somehow convinced Medicare that it does not need physicians to take care of patients with diabetes mellitus. It simply needs industry designated healthcare providers to run nurse call centers.
"The eight selected Medicare Health Support Organizations (MHSOs) are well known in the industry and vary in size, complexity, and organizational focus. Some focus primarily on the provision of care management services, while others provide a broader range of services (including commercial insurance products, information systems, etc."
Patients with Diabetes Mellitus need medical care and not commoditized healthcare. The patient physician relationship is critical. The physician has to be the manager of a chronic disease team with the patient being the player and the physician extenders being an extension of the physicians care. This model of nurse directed health desk has not worked in the past and can not work now.
"Each MHS program has a nurse-based health coaching and health support program; however, the MHSOs vary in how they implement the various components of their model. While all MHS interventions involve a telephonic nurse component, only five of the MHSOs are actively engaged in serving an institutionally based population."
If the experiment is set up incorrectly the results are meaningless and a waste of money. The fighting over where it worked, whether the government gave the study enough time and whether the results are valid have begun.
No matter how much time the government gives the study it will fail. The study was doomed to failure before it started. It does not mean the concept of disease management is a failure.
Did the study prove that disease management is ineffective? I do not think so. It simply proved that the design of the study was defective? If 90% of the healthcare dollar is spent on the complications of chronic disease, the healthcare system must figure out an effective way to decrease the complications. This is where the money is!
The concept of disease management is in jeopardy because the media is the message and the message of the study is wrong.
Physicians were not involved in this disease management project. One of these days the government is going to realize that medical care is different than healthcare. Physicians provide medical care not healthcare. Medical care should be driven by physicians, not corporations and its executives.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.