UNITING PHYSICIANS & PATIENTS AS A VOICE IN HEALTH CARE
HMOs, managed care organizations and other health insurers are increasingly providing "disease management" services. Having these services provided by the insurer, rather than physicians and hospitals, is bad health care policy, may violate patient privacy and is not cost-effective. The Minnesota Physician-Patient Alliance believes insurers and managed care organizations should not provide disease management. Rather, doctors, hospitals and health care organizations should be reimbursed for providing clinical care including what managed care organizations refer to as disease management.
Disease management by insurers evolved from services formerly provided by physicians and hospitals. In the 1970's and 80's, providers across the country used disease management protocols to coordinate care, improve quality and reduce health care costs. Disease management techniques meld health education, social services and care management in order to help patients with chronic disease and achieve optimal health outcomes. Also, patients recovering from acute care episodes benefit from coordination and continuity of care at the appropriate level of service.
During the 1990's, two trends combined to move disease management out of doctor offices and hospitals and under the purview of health insurers and their contractors. The first: insurers reduced reimbursement to doctors and hospitals and stopped paying for disease management services. The second: insurers began using funds diverted from providers to pay for, among other things, their own "disease management" services. Estimates are that insurers expenditures for disease management exceeded $1 billion in 1999.(1,2)
In Minnesota, the three insurers that cover approximately 90% of Minnesotan's commercially insured population each have extensive and growing disease management programs. Meanwhile, hospitals and doctors in Minnesota have seen steady declines in their reimbursement levels and are rarely reimbursed for providing disease management and case management services. For example, reimbursement to physicians for care of patients requiring counseling to manage a complex of multiple diseases (including telephone calls) is usually not reimbursed by Minnesota health plans. Meanwhile, telephone calls from a 'disease management' person employed or contracted directly by the health plan and ignorant of the intimate details of a patient's complex multiple problems, are reimbursed by these very same insurers with the justification of improving quality of care.
The widening role of insurer disease management is exemplified by Blue Cross Blue Shield of Minnesota's "BluePrint for Health". In December 2001, BCBSM signed a 10-year contract valued in the hundreds of millions of dollars for disease management services with American Healthways, Inc., a publicly traded company (NASDAQ ticker "AMHC") based in Nashville, Tennessee(3). Using data from enrollment forms and insurance claims, BCBSM identifies people who apparently have chronic health conditions and, without consent from these people, gives their names and phone numbers to American Healthways. American Healthways then contacts these BCBSM enrollees and attempts to enlist them in their "disease management" program. BluePrint for Health has expanded from an initial focus on three conditions (diabetes, coronary artery disease, and high risk pregnancies) to cover, as of June 2003, 18 different medical diagnoses.
Disease management as practiced by HealthPartners, another of the three big Minnesota health plans, is similar to the BCBSM approach. Rather than contract externally, however, HealthPartners has established an internal department called the "Center for Health Promotion" charged by HealthPartners with accomplishing "total population management (TPM)... focusing on an entire population and managing all levels of severity of a particular disease."(4) In the year 2000, HealthPartners set goals for its "population" within five years. To accomplish these goals, HealthPartners "assesses the risk status of its population through claims data, chart audits and Internet-based risk assessments, and stratifies them along a risk continuum."(5) Specific techniques used by HealthPartners include "patient and provider education materials, health education courses, phone-based counseling, work site health promotion programs, and community health promotions."(6)