The Merits of Disease Management

This past spring, the U.S. House Ways and Means Subcommittee on Health held a hearing on the benefits of disease management (DM) initiatives. The hearing focused on the role DM may serve in the Medicare fee-for-service (FFS) program, including projects the Bush Administration is implementing to allow DM services to be made available for those on Medicare.

Humana is focusing on disease management as a core strategy for addressing medical management. Its programs have already produced positive results in several areas such as:

• 90 percent of patients in Humana's Congestive Heart Failure program (see story on page 5 in the summer issue) showed stabilized or improved disease status, with 62 percent showing a reduction in hospitalization.
• A significant number of Humana members in the End Stage Renal Disease program met their dialysis adequacy targets at a higher percentage when compared to the national average listed through the U.S. Renal Data System (USRDS). Hospital bed days were 45 percent lower than the USRDS average, and ER visits decreased by 75 percent over two years.

At the hearing, Jack Lord, M.D., chief clinical strategy and innovation officer for Humana, testified about how health plans, specifically Humana, have implemented disease management programs. He is currently the president of the Disease Management Association of America.

Here are excerpts from Lord’s testimony:

• Disease management provides disciplined, evidence-based, expert-approved support for individuals with chronic conditions to help them become more aware of their condition and of their treatment choices, to change their behavior to reduce their health risk, and to bridge their relationships with their physicians.
• Patients become more engaged in managing their own health care, take better care of themselves, get care that experts say they should be getting, avoid care that does them little good, improve their compliance with drug regimens, and generally experience improved health and functional status.
• Disease management programs are increasingly more prevalent. A survey last year by the American Association of Health Plans found that the average plan had at least five disease management programs, usually focusing on diabetes, coronary artery disease, congestive heart failure, asthma, high-risk pregnancy and depression.
• Disease management supports the patient's self-management and uses evidence-based treatment information as a basis for coaching the patient and providing timely information to the practitioner.
• Disease management programs emphasize the coordination of service between the treating physician and nurse case managers, educators, pharmacists and other heath care professionals.

More information about DM is available through the Disease Management Association of America, www.dmaa.org.

ESRD Early Referral Initiative Seeks to Improve Outcomes

In the five years since it was implemented, Humana's End Stage Renal Disease management program, provided through RMS Disease Management Inc., has helped to substantially reduce hospitalization rates and decrease mortality for members with ESRD. Hospitalizations are down 40 percent, and mortality has decreased 20 percent. In addition, a recent analysis of patients managed under the ESRD program found that Humana members' clinical outcomes surpassed national benchmarks for the fifth consecutive year.

The primary reasons for the ESRD program's success is the earlier identification and management of comorbidities and more coordinated care, said John Dickmeyer, M.D., RMS' senior vice president for medical management. "The RMS program places an intense focus on management of comorbid conditions, such as diabetes, anemia and cardiovascular disease, which has led the way to continued clinical improvements each year," he said. "But as the incidence of ESRD continues to grow at an exponential rate, the challenge is to reduce the prevalence of ESRD among Humana members."

RMS and Humana have found that the majority of ESRD patients are starting dialysis in the hospital and have not been educated regarding the options for treatment. For that reason, Humana and RMS are encouraging primary care physicians to refer patients with chronic kidney disease (CKD) to nephrologists for organization of the transition to dialysis. These referrals should occur when the serum creatinine is greater than 3.0 Mg% or the glomerular filtration rate is less than 25 cc./min, according to the National Kidney Foundation's Kidney Disease Outcome Quality Initiative Guideline. RMS nursing staff can assist with educating these patients. "We are confident that most patients could remain healthier and start dialysis in the outpatient setting, if they were properly prepared," Dickmeyer noted.

In addition, there is increasing evidence that better control of blood pressure, careful monitoring of diabetes and the use of ACE inhibitors not only lowers the cost of caring for CKD patients, but also delays the progression to ESRD. Recommended care guidelines and educational materials are now available for CKD patient education regarding this critical health care issue, through the National Kidney Foundation Web site, www.kidney.org.

This program is not available in Tampa. Nephrology Care Services Network is the ESRD program vendor in Tampa.

For more information on the ESRD program in Tampa, call Susan Carol, disease management manager, at 386-676-1833.