Prevention Through Intervention

Contributed by:

Elisabeth Pena

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ISEASEMANAGEMENTISMAKINGACOMEBACK. Health plans are renewing their interest in the old buzz word from the early 1990s as a way to address soaring healthcare costs. Pharmaceutical companies are noting this trend, and some are jump ing right in with new programs to take advantage of this opportunity. Disease management, regarded by some as the future of healthcare in the United States, calls for medical professionals and insurers to moni tor and support patients with known chronic conditions, promoting self care as a way to prevent acute episodes requiring hospitalization. Experts say 5% of the U.S. population has a highrisk medical con dition, accounting for more than 50% of the country’s healthcare costs. In addition, chronic illnesses have been found to affect more than 100 million Americans and account for 75% of the nation’s annual health care costs. The diseasemanagement industry targets these patients, seeking to reduce the severity of episodes and to cut overall healthcare costs. Louise Gillis Prevention Intervention It’s in the pharma industry’s best interest to develop DISEASEMANAGEMENT PROGRAMS that can bring additional sales and longterm relationships with payer organizations, as well as fill a void created by recent restrictions on sales reps’activities with physicians. T HROUGH D In the past 18 months, the tide has begun to turn and the industry is starting to again focus on disease management. In the early to mid1990s disease management was a major catch phrase. BY ELISABETH PENA 32 S e p t e mb e r 2003 PharmaVOICE 33 PharmaVOICE S e p t e mb e r 2 003 DISEASE management According to the Tufts Center for the Study of Drug Development, diseasemanage ment program accreditation will rise, with 15 new diseasemanagement firms expected to be accredited by the National Committee on Quality Assurance in 2003, up from the 10 that were first accredited in 2002. In addition, pharmaceutical companies are beginning to seek accreditation for diseasemanagement programs. (See box on page 36.) “In the early to mid1990s disease man agement was a major catch phrase,” says Louise Gillis, associate VP at Market Mea sures/Cozint. “In the past 18 months, the tide has begun to turn and the industry is starting to again focus on disease management.” According to AirLogix’s Susan Riley, presi dent and CEO, John Cover, VP of sales, and Barry Zajac, VP of clinical informatics, more organizations are turning toward disease man agement as a strategy to improve quality and MARKET MEASURES/COZINT’S SHARED ACCESS STUDY ON THEMANAGEMENTOFHYPERTENSIONBYMANAGEDCARE ORGANIZATIONS (MCOS) WAS COMPLETED IN OCTOBER 2002. THE COMPANY ALSO CONDUCTED A STUDY ON THE MANAGEMENT OF DEPRESSION AND ANTIDEPRESSANT FORMULARIESBYMCOS IN JULY 2002. This research was designed to assess formulary and diseaseman agement practices employed by MCOs in the hypertension and depression categories and to explore key issues in these markets that may have a significant impact on managed care. HYPERTENSION MM/C interviewed 26 pharmacy and medical decisionmakers from HMOs.All 26 of the HMOs covered anywhere from 100,000 lives to millions of members. The total number of HMO lives covered by these plans is more than 7 million. These 26 HMOs represent about 17%of the 46.7 million lives covered by HMOs in the United States. Aboutonequarterof theseHMOshavedeveloped hypertension disease management (DM) programs. . DM programs among these HMOs are primarily designed to identify hypertensive members and monitor their treatment.A few are part of a compre hensive cardiovascular program rather than specific to hypertension. . Pharma manufacturers participate in very few of these programs. . A few respondents indicate that DM support offered from compa nies has not fully addressed the specific needs of their HMOs, including a respondent who commented that he wants unbiased information. . One respondent describes an existing manufacturer that produces HMO physician and patienteducation programs. The HMO indepen dently identifies and recruits members and is recognized as the spon sor; the manufacturer provides the program and speakers. DEPRESSION MM/C interviewed 27 pharmacy and medical decisionmakers from HMOs.All 27 of the HMOs covered anywhere from 100,000 lives to millions of members. The total number of HMO lives covered by these plans is more than 15 million. These 27 HMOs represent about 33% of the 46.7 million lives covered by HMOs in the United States. . DM programs are important to about half of the participating MCOs, although complying with the Health Plan Employer Data and Information Set (HEDIS) measures and maintaining National Commit tee for Quality Assurance (NCQA) accreditation are of even greater interest. MCOs do not appear to be interested in manufacturerspon sored diseasemanagement programs. . Nearly onethird of participants maintain that these programs are important because they aid the MCO in complying with HEDIS and NCQA measures,which enhance the marketability of the plans. . Greater than onethird (11 of 27 respondents) of participating MCOs have DM programs for depression, which are primarily devel oped and implemented internally. A few MCOs have developed these programs with the aid of their behavioral health carve out. . Only three respondents report that pharma manufacturers support their MCOs’ programs. A few other MCOs are seeking to develop DM programs and plan to do so internally. . A couple of respondents mention that they donot want a “cookiecutter”approach to DM, implying that the programs offered by manufacturers may not be customized enough or may not include all of the ele ments that would meet their needs. Moreover, one respondent notes a concern that manufacturerspon sored programs would promote particular agents. . One participant says it would not be possible to maintainpatientconfidentiality if a third party,such as a manufacturer,were to be involved in the program. . The current DM programs primarily focus on screening patients for depression, provider and patient education, and promotion of patient compliance to medications. . Among these MCOs,DM programs primarily have been initiated to satisfy HEDIS measures and NCQA accreditation requirements. . Virtually all of these MCOs (24 of the 27 respondents) follow HEDIS measures.The value to these MCOs seems to be more directly related to the marketability of their programs than to any other factor. Notably, while many employers are not interested in DM programs, responses imply thatemployersare interested inpartneringwithMCOs thatencour agequality of care as reflected in HEDISmeasures.Beyondachievingbet ter marketability of their programs, a couple of respondents express an appreciation of the quality of care that NCQA encourages. Source:Market Measures/Cozint LP,East Hanover,N.J.For more information,visit mmiresearch.com. Disease Management and MCOs Hypertension and Depression Studies THIS RESEARCH WASDESIGNEDTO ASSESS FORMULARY ANDDISEASE MANAGEMENT PRACTICES EMPLOYED BY MCOS. M 34 S e p t e mb e r 2003 PharmaVOICE DISEASE management satisfaction while reducing costs. AirLogix pro vides diseasemanagement services for condi tions such as asthma and COPD. A sign of change is the increased level of selectivity and sophistication with which health plans and other healthcare purchasers are inves tigating and making decisions about what dis ease states to pursue, what program components are desirable, whether to make or buy, and what vendors to use. The question, AirLogix execu tives ask, is no longer whether to do disease management, but how much? Disease manage ment is becoming a serious consideration across the healthcare spectrum, and scientific advances could help to advance the goal of prevention. “The next couple of years are going to be really exciting in the area of disease manage ment,” says David Krause, Ph.D., an instruc tor at Marquette University and a healthcare consultant for Accordant. “Not only because Medicare is getting involved in disease man agement, but because the rapid advancements in genetics is helping us better understand what therapies may or may not work in the treatments of chronic diseases.” According to Jim Knipper, president and CEO of J. Knipper & Co., several factors are driving interest in disease management. “The babyboomer population is aging and becoming more aware of the future cost burden of quality healthcare,” he says. “The health insur ance industry and MCOs see the potential for their insurance products becoming too expensive for the market. Washington is being pressed by the issue and is being called upon by various con stituencies to respond in ways that may nega tively affect the industry. Our industry continues to be under pressure to justify medications as a reduced cost healthcare strategy compared with hospitalization and longterm care.” Managing Diseases The Disease Management Association of America (DMAA) defines disease manage THE CHALLENGES AND PROBLEMS WITH DM PROGRAMSHAVEBEEN OVERALL COST,EDUCATINGTHE PATIENT ANDHEALTHCARE PROFESSIONAL EFFECTIVELY, ANDQUALIFYING/QUANTIFYING THE RESULTS. Jim Knipper THEDISEASE MANAGEMENTTREND IS DEFINITELY EMERGINGAGAIN ANDTECHNOLOGY PLAYS ABIGROLE IN THAT.THETHINGS THATPEOPLE ENVISIONED ARE ACTUALLY POSSIBLE NOWTHANKSTO THE INTERNET. Eric Bolesh THECHALLENGEWITH DISEASE MANAGEMENT IS SHOWINGTHATTHE PROGRAM IS THE STRATEGY THAT IS IMPROVINGTHE HEALTHOFTHEMEMBERS ANDTHATWEARETHEONES DOING IT. Dr. Michael Cousins DISEASE MANAGEMENT,BY DEFINITION, IS CHANGINGTHE BEHAVIOR OFDOCTORSOR PATIENTS OROFTENTIMESBOTH ANDTHAT IS TOUGHTODO. Edward Rhoades THERE IS AN INCREASING TRENDTOWARD INDIVIDUAL IZED CARE IN ALMOSTEVERY DISEASE CATEGORY.THENOTION OFDIAGNOSINGPATIENTSAND PROVIDINGTHEMWITHAN INDIVIDUALIZED REGIMENTHAT SUITSTHEIR NEEDS ISWHERE MEDICINE IS GOING. INTHAT SETTING,COMMUNICATION IS GOINGTOBEMORE IMPORTANT THANEVER. Al Paz MOSTMANAGEDCARE ORGANIZATIONS HAVEREALIZEDTHE VALUEANDHAVE IMPLEMENTED DISEASEMANAGEMENTPROGRAMS. MOSTCOMPANIES FIND IT WORTHWHILETO IMPLEMENT PROGRAMS FORTHEMOSTCOMMON CONDITIONS,SUCH ASDIABETES, ASTHMA,ANDHEARTDISEASE. Dr. Richard Petrucci 36 S e p t e mb e r 2003 PharmaVOICE DISEASE management ment as a system of coordinated healthcare interventions and communications for popula tions with conditions in which patient self care efforts are significant. Disease manage ment supports the physician or practitioner/ patient relationship and plan of care; empha sizes prevention of exacerbations and compli cations using evidencebased practice guide lines and patient empowerment strategies; and evaluates clinical, humanistic, and eco nomic outcomes on an ongoing basis with the goal of improving overall health. Historically, disease management has used claims, pharmacy, and lab data to identify costly, highrisk patients and assign those patients a case manager. The case manager’s job is to help patients comply with a treat ment program to reduce the overall cost of care by preventing further acute incidences from occurring. Diseases typically targeted by diseaseman agement programs include diabetes, asthma, congestive heart failure, cystic fibrosis, hemophilia, and multiple sclerosis. According to Warren E. Todd, executive director of The DMAA, disease management lowers the demand for expensive hospitaliza tion as well as potentially slowing the progress of disease in an individual. “We can no longer deny the aging of America or the chronic disease crises in Amer ica, and disease management appears to be one of the laststanding strategies,” he says. Patients, however, typically will not seek access to diseasemanagement programs, therefore companies need to find ways to get the patients on board. “Individuals are not likely to reach out on their own for these types of initiatives,” says GLAXOSMITHKLINE RECENTLY BECAMETHE FIRST COMPA NY TO RECEIVE CERTIFICATION IN DISEASE MANAGEMENT FROMURAC,A LEADER IN THE ACCREDITATION OFHEALTH ANDMANAGEDCAREORGANIZATIONS. GSK’s HealthCare Management Group received core accreditation and was certified in disease management for asthma, migraine, and smoking cessation. The company also was the first pharmaceutical company to receive certification in diseasemanagement content and program design from the National Committee for Quality Assurance (NCQA), a private, nonprofit organization dedicated to improving healthcare quality, and will be pursuing certification from the Joint Commission onAccreditation of Healthcare Organizations (JCAHO),an independent, nonprofit organization that evaluates and accredits nearly 17,000 healthcare organizations and programs in the United States. To achieve URAC certification, companies must first comply with URAC’s principles for core accredi tation. Companies then selfselect up to 50% of the standards from any URAC accreditation module and mustdemonstratehow their product or service com plies with the selected standards. Upon completion of a rigorous review process by URAC, companies receive URAC’s Core Accreditation, plus certification in the selected module or modules. “We are committed to pursuing diseasemanage ment certification because it demonstrates to healthcare organizations that we are bringing evidencebased disease management programs reviewed by healthcare standard organiza tions, such as NCQA and URAC,”says Tim Klapish, executive director of HealthCare Management at GlaxoSmithKline. Mr. Klapish says GSK is serious about developing the right disease management programs to address the appropriate use of the compa ny’s medicines and address underdiagnosis and inadequate care. “As we bring innovation around medicine, we hope to couple that with innovative approaches, such as disease management, to help improve the care of the chronically ill,” he says. According to Mr. Klapish, diseasemanagement certification also presents the company with a competitive advantage because it demonstrates that the company’s diseasemanagement tools and interventions are built on evidencebased clinicalpractice guidelines and patient identification and stratification,and they address inappropriate use and inadequate care. “Coupling what we are doing from a disease management perspective with the innovative medicines GSK has in the market is an enormous competitive advantage,” he says. “Decisionmakers at health plans know if a company has certification it meets what the health plans are required to do. In addition, medical directors don’t have to review everything because they know the policies and pro cedures and approaches that we took are sound fundamentally and clinically.” GlaxoSmithKline:Disease Management Certification Our diseasemanagement programs are developed with the express intent of delivering educational materials and tools to organizations wishing to implement such programs. The programs are structured to be flexible and to meet individual needs of an implementing organization. Tim Klapish 37 PharmaVOICE S e p t e mb e r 2 003 F DISEASE management Rick Milde, VP at Access Health Risk Man agement. “The most effective way to reach patients is to go to the various channels at the community level.” In addition, disease management benefits patients by providing better care to the patient at all times, not just when a condition is exac erbated, thereby reducing the costs of hospital ization or other more expensive care. “Medical literature would suggest that, for some chronic diseases, members receive less than optimal care,” says Richard Petrucci, M.D., VP for chronic case and disease man agement at Oxford Health Plans Inc. Disease management also goes beyond improving the health of the patient to improving the health processes used by health plans. “A key area to focus on is the improvement of health process and health status outcomes,” says Michael Cousins, Ph.D., director of health informatics at Health Management Corp. (HMC). “Improving health outcomes means making sure, for example, that mem bers who have coronary artery disease are get ting their LDL tests and taking medications as prescribed. We are working directly to improve the process. When we get the plan’s members to take their tests or refill their medications, then we can say we’ve made improvements in health process measures. And when we do this, we improve the mem bers’ health.” One way that HMC is working to improve health processes is through the recent launch of AccessHMC, a Webbased interface that pro vides its health plan clients with access to com prehensive program information. The program allows HMC and its clients to better manage members through rapid response to issues revealed through the shared informa tion, which, in turn, helps to improve health outcomes. The concept of disease management also is being transformed beyond managing a dis ease in a patient to managing a population with the condition. Since patients often have comorbidities, population management is about meeting the needs of the individual patient with different chronic conditions to provide improvement in population health. “The industry is beginning to realize that structured programs can add value in terms of delivering care to a population of patients,” says Terry Crowson, M.D., associate medical director at HealthPartners. “We are evolving from thinking more about population man agement than disease management.” According to Al Paz, CEO, Euro RSCG Life, Marketing Services Group, the key to disease management is individualizing care. “Programs need to address the needs of the patient, family, the financial situation, and come up with a recipe of services and products that enable that patient to reach his or her therapeutic goal,” Mr. Paz says. From Theory to Practice “The commitment of pharmaceutical com panies to disease management is beyond inno vation of medicine,” says Tim Klapish, execu tive director of disease management at GlaxoSmithKline. “It is to develop the right complementary tools and services defined as disease management. We believe that it is important to address the appropriate use of our medicines, as well as underdiagnosis and inadequate care.” According to Eric Bolesh, a senior analyst at Cutting Edge Information, for pharmaceu tical companies disease management and physician outreach is about shifting the focus to lifetime customer value. “Pharma companies realize that, with many prescriptions, it is one and done; the patient is sick, takes a product, and then is all right,” Mr. Bolesh says. “The focus is on retaining those customers and creating a long running relationship with doctors, patients, pharmacists — everyone involved in health care. Disease management is one more tool in that arsenal to building longterm relation ships with all those stakeholders.” Patient adherence and persistency has been one of the biggest topics in the industry and government for more than 10 years. The phar maceutical industry has and continues to devel op adherence and persistency programs as a win win for patient, insurers, and government. “Of all new scripts written, perhaps 20% or more never get filled,” Mr. Knipper says. “In the first year only 70% of the scripts will be refilled. This is especially true for asymp tomatic disease states such as high cholesterol and hypertension. Year two drops off dramati cally from year one. Year three is even worse. Patients who take their meds according to the suggested regimen tend to stay healthier, visit the emergency room less, and therefore lower costs to the healthcare system.” In addition to creating a relationship with patients who may only require shortterm treat ment, diseasemanagement offers pharmaceuti cal companies a way to deal with the problem of compliance in patients with chronic conditions. “In a new cohort of patients starting on a chronic therapy, on average patients fill about 4.5 to 5 prescriptions in a 12month period and then quit,” says Edward Rhoades, senior VP of marketing and new business at Catalina Health Resource. “If one looks at the overall bill for drug spending, clearly a patient who only takes four prescriptions of a chronic ther apy is a problem. Drugs are costeffective, but only if taken properly, and that means persis tence and compliance. The way that many patients take drugs is costing the industry bil lions in lost sales and the healthcare system even more in lost savings. The drug companies could really help themselves by doing more to support patients where appropriate.” Disease management also is inherently compatible with the financial interest of phar maceutical companies, Mr. Todd says. “If disease management is working, then the patients are not only on the right medica tion, but they are being compliant with their medications,” he says. “They are actually adhering to therapies and filling prescriptions; that tends to increase the volume of pharma ceuticals produced and consumed.” Disease management also may be benefi cial to pharma companies since an increase in the volume of prescriptions could offset the recent decline in the number of new pharma ceutical products entering the market. “It is very important for companies to look at their portfolio of products and figure out how they are able to get additional growth out of even mature brands in their portfolio,” Mr. Paz says. “Disease management is a very effec tive way to do that. If a company can use new and old products to improve the quality of care of patients then it is able to significantly increase sales. With disease management, a pharma company is able to provide services that go above and beyond what can be offered if it is only selling a patient one product.” Another factor that is propelling the phar maceutical industry’s renewed interest in disease management is the recent restrictions placed on physiciandirected promotional programs. “The pharma industry is no longer uncon strained concerning its promotional strategies directed at prescribing physicians; companies need new vehicles and ways to create both a marketing advantage and programs that can produce overall cost savings,” Mr. Todd says. “Disease management appears to be filling part of that void.” Analysts at Datamonitor Plc. have found that diseasemanagement programs provide an additional benefit to pharmaceutical com panies in the form of relationships with payer organizations. Pharmaceutical sponsorship of a diseasemanagement program allows the 38 S e p t e mb e r 2003 PharmaVOICE DISEASE management PREDICTINGTHEFUTUREOFHEALTHCARETECHNOLOGY IS DIFFICULT WITH ANNUAL INCREASES IN HEALTHCARE COSTS ANDORGANIZATIONAL BUDGETCUTS. The same factors that present the greatest challenges have now become the drivers of technology trends that seek to manage areas of financial difficulty. A recent industry survey, conducted by Healthcare Informatics, identified nine technology categories that will support improvedefficiencies andhealthcare delivery costs and services.Among these top information technology categories is disease management. Louisiana State University (LSU) Health Science Center, Shreveport, La., is among the manyhealthcare organizations already using techno logical advancements to improve clinical and financial outcomes. Richard Mansour,M.D.,an associate clinical professor of medicine at the FeistWeiller Cancer Center at Louisiana State University (LSU) Health Sciences CenterShreveport, and chief medical officer for Eclip sys Corp., outlines how diseasemanagement technology resulted in a significant return on investment. The center installed a diseasemanagement solution specially designed for oncology practice. The oncology solution is designed to perform three critical tasks:provide access to uptodate knowledge at the point of care, reduce variability in care delivery and treatment,and monitor and measure outcomes. The solution,which was implementedabout four years ago,saves the center both time and resources by automating oncology clinical trials, protocols,and regimens.With this system in place,LSU Health Science Center clinicians can prepare, review, and print a wide range of patient data, including demographics,orders,protocols,cancer staging,med ication administration, lab and radiology results, vital signs, statistical summaries, and charges. Most impor tantly, this information is available electronically from anyworkstation fromwithin thehealthsciencecenter, providing immediate access to information and knowledge that aids caregivers in decisionmaking. To maximize the value of the system, the health center created a number of customized protocols to reflect its own established best practices. This feature is especially important to the center’s nearly 150 open clinical trials,focusing on the treatment of prostate, breast, and lung cancers. In addition, Health Sci ence Center oncologists are able to create customized flow sheets that incorporate all activities associated with a patientcare plan, including chemotherapy dosages, physician visits, tests, and procedures. Flow sheets created in the system include a comprehensive display of order sets and order status. Approved orders trigger the delivery of services by specific healthcare providers within the organization, including pharmacy, lab, radiology, or nursing. Orders entered directly by physicians into the clinician order entry module of the system are processed immediately. This reaps multiple benefits, including eliminating the risk of illegible handwriting, inaccu rate verbal communication, lost orders and orders delayed by incorrect information, or information being routed to the incorrect department. Furthermore, by automating the processes, the center eliminates the potential for error at task handoff, when medical errors are most likely to happen. Once completed,results,orders,and related charges are automatical ly available to thehealthcenter’s caregivers.Rules andalerts notify physi cians if any potential drug allergies or drugdrug interactions exist. The oncology solution significantly improved the costeffectiveness of oncology drug prescribing.As a result, the LSU Health Science Center achieved a $186,000 cost reduction during a twoyear period by chang ing prescribing patterns for antiemetic drugs. The system also helps oncologists make consis tent selections of antiemetic agents over time and prepares orders for the physicians based on agreed upon treatment plans. Additionally, in automating the process, the health center has experienced reduced reliance on paper. Caregiver efficiency has improved by eliminat ing the need to locate paper charts. The health sci ence center also has reduced turnaround times and redundant data collection. Disease Management in Practice: Louisiana State University Health Science Center To maximize the value of the system, the health center created a number of customized protocols to reflect its own established best practices. An outline of how disease management technology resulted in significant return on investment at LSU Health Science Center. Dr.Richard Mansour 39 PharmaVOICE S e p t e mb e r 2 003 P DISEASE management pharmaceutical company to work with the health plan, for example, by jointly inviting patients to participate. Not only does this increase the chances that patients will sign up, it may also serve to gain the product a pre ferred place on formulary. In addition, challenges to implementing dis easemanagement programs, such as cost and legal concerns, can be mitigated by limited phar maceutical involvement through sponsorship, Datamonitor analysts say. Mr. Rhoades agrees phar maceutical companies can aid diseasemanagement ini tiatives through funding. “Pharma companies make the lion’s share of the profit in the healthcare industry because of intellectual prop erty protection, which is appropriate,” he says. “When it comes to funding these programs, the pharma com panies are the natural choice, as they have the incentive and the money. The challenge for pharma is actually reaching patients to help them.” Managedcare organiza tions, however, often do not want a diseasemanagement program sponsored by a pharmaceutical com pany. “Managedcare organizations don’t want help from pharma because they don’t want a veiled promotion,” Ms. Gillis says. “They want something that is going to help manage the patients who are in their plans. They would prefer funding from pharma companies to help develop the programs.” Ms. Gillis says if pharmaceutical companies tailor diseasemanagement programs to a man agedcare organization’s population instead of developing a blanket program, then the man agedcare organization would be much more willing to work with pharma companies. Dr. Petrucci has had experience working with pharma companies on diseasemanage ment components through his work at Oxford Health Plans and believes the two entities can work together to the patient’s advantage. “Many pharmaceutical companies produce diseasespecific literature that is distributed to diseasemanagement members to help them better understand their condition; many man agedcare organizations partner with pharma ceutical companies in this regard,” he says. “This information does not promote individu al drug products and is value added to Oxford’s diseasemanagement program. Some pharmaceutical companies also cosponsor CME programs with Oxford to educate physi cians about the value of disease management.” Physician Focus Physicians are a crucial piece of the disease management puzzle. Diseasemanagement providers do not practice medicine, physicians do; without physicians, DM programs would not be possible. According to AirLogix execu tives, diseasemanagement programs are designed to empower patients to change behav ior, without physician participation, buyin, and support, many patients would not participate. But getting the healthcare community to embrace disease management can be challeng ing for all parties involved. The current healthcare system is set up to care for acute ill ness, not chronic diseases. Disease manage ment offers a populationbased approach to address the needs of the chronically ill with physicians functioning in a pivotal role. “We view the role of the physicians as real ly the role of a coach, someone who can pro vide direction to patients, be a mentor, give them the right action plans, and help them navigate through the healthcare system,” Mr. Klapish says. “It is a lot to ask physicians to do all they are expected to do on top of trying to drive behavior change, such as trying to get patients to take better care of themselves and essentially getting patients to take ownership of their condition. Disease management and the role of the medical group is becoming more important every day.” Datamonitor’s February 2002 Physician Insight Survey shows that physicians support disease management. In a survey of 90 psychi atrists and general practitioners in the United States, Germany, and France, physicians believed that a greater proportion of their patients would benefit from diseasemanage ment tools. In the United States, physicians reported that less than 25% of those who would benefit from diseasemanagement tools are actually using them. One reason analysts believe diseasemanagement programs lost popularity in the past is that physicians viewed pharma’s participation as selfpromotional. “A pharma company’s business model and the desire to create a diseasemanage ment program might be at cross purposes in the long run,” Mr. Bolesh says. “To combat that, pharma compa nies are trying to reach out to physicians and establish themselves as sources of infor mation. Anytime a pharma company reaches out to patients or physicians or the public at large, the companies shouldn’t position themselves as sales people; they should position them selves as service providers and develop the sales rep as a provider of information.” Diseasemanagement programs supported by pharma companies, however, may be win ning physician support. About 80% of U.S. physicians surveyed by Datamonitor reported that they would not be swayed from participa tion in diseasemanagement applications based on the fact that the program was spon sored by a pharmaceutical company. Often a third party is viewed as the most objective source of information by a physician. In an ideal scenario, Dr. Cousins says, the health plan and diseasemanagement program are working together with the patient and the provider community. “It is critical to engage providers and get them on board and have them understand that this is a valueadded service to them,” he says. “We have many providers, for example, who welcome our involvement because they have been trying to reach a particular patient or are having difficulty with the patient following the plan of care. We make telephone calls to reinforce the plan of care, to remind patients that they haven’t had a test, and encourage them to contact their provider.” eDisease Management programs are able to significantly improve outcomes in chronically ill patients Source: Legrow and Metzger, Datamonitor 40 S e p t e mb e r 2003 PharmaVOICE T DISEASE management But, involving the providers can be a chal lenge, according to Mr. Rhoades, because of the rate at which people change their health plans; the average amount of time a patient stays within one managedcare plan is between one and two years. “A managedcare company could spend a lot of extra money to manage a patient’s chronic condition and the odds are that the patient is going to leave the plan before the provider benefits from, say, a saved trip to the hospital,” he says. “Except for conditions that have a fairly high rate of acute episodes, such as congestive heart failure and asthma, it is hard for managed care to recoup the invest ment. Pharma companies need to do more direct outreach to patients to educate, encourage, even remind them to stay on the therapy. Funding outreach at the point of care — pharmacies and doctors’ offices — can be very effective when there is scale.” Technical Incentives Mr. Bolesh believes technology is helping to drive the reemergence of diseasemanage ment programs. Ms. Gillis agrees, saying technology will aid disease management in terms of conve nience for the patients. “If a highrisk patient has Internet access, case managers could send email reminders instead of calling or visiting,” she says. “For example, an email could be sent to remind diabetics to get their eyes checked every six months.” Affordability is at the crux of technology’s role in disease management. Providing indi vidual attention to patients is made feasible for a company by using email and other elec tronic means. “The Internet makes communication with large and broad audiences affordable,” Mr. Paz says. “Previously, it was prohibitive for a pharma company to reach out to the millions of patients who use their medications. Through the use of the Internet, a company can establish a relationship with its cus tomers at a very affordable cost and that com munication can then be customized to the needs of that particular customer.” “A lot of the cost of disease management interventions is associated with labor, such as a nurse on a phone line,” Mr. Todd says. “Technology offers us the opportunity to intervene with the patient creatively at a lower cost.” “Less than 40% of the population has reg ular contact with the Internet,” Mr. Knipper says. “The growing population of Internet users are youths, which represent the future market. The Internet will play an increasing role in communicating with healthcare providers. I can envision the day in the not sodistantfuture when healthcare providers use the Internet as a significant method of attending to their patients. Internet monitor ing services reporting patient conditions to the physician/remote healthcare center could well be an industry of the future. Handheld devices, such as PDAs, at the present time are still relatively expensive, so unless there is a very serious disease state, a highly motivated patient, and a very low cost handheld device available, the potential enhancement to dis ease management will not be as effective as other patientcentric programs.” The healthcare professional’s role in dis ease management can be enhanced by adding enabling technology to the mix. “Pharma companies aren’t interested in replacing the healthcare professional in dis ease management,” Mr. Bolesh says. “Com panies want to set up a relationship triangle where they are at one point and the patients are at another point and the healthcare providers and primarycare providers are at the third point. All three parties interact with each other to add value to the patient’s disease management. Pharma companies are looking to strengthen the relationship between the patient and the nurse or physi cian because by doing so they reinforce their own position.” Additionally, Dr. Crowson says electronic enhancements have allowed for better inte gration of best practices into physician offices, including better population manage ment and the building of registries so that systems can track what is happening with patients. “Electronic medical records that are being developed will provide a lot of capabilities when they are fully implemented for better disease and population management,” he says. According to Robert Drazen, president of Access Health Risk Management, technolo gy is the future of disease management. “Our RiskID is a simple software screen ing tool that screens for risks of potential dis ease and then stratifies individuals into cate gories, such as low risk, moderate risk, and high risk,” Mr. Drazen says. “Reducing chronic disease risk factors for highrisk patients is accomplished through education, behavioral modification, or proper clinical treatment. This reduces their risk potential to the point where chronic disease and the related costs can be prevented. The result is that overall healthcare costs are reduced and patients have the tools and understanding to better manage their healthcare.” The conveniences and benefits of disease management technologies, however, compete with a general population that is still uncom fortable with providing personal health information via the Internet. “There will be a cultural change that will take time and maybe in a few years people will be much more comfortable sharing information,” Dr. Krause says. “But an explo sion of using the Internet to transmit infor mation between individuals that have a chronic illness, diseasemanagement compa nies, and their physicians and providers has not happened at nearly the rate that was pre dicted.” According to Mr. Milde, consumers are concerned about the use of their health infor mation and who gets to see it. “One of the big concerns, both from the individual, as well as from the community or the employer, is that a bigbrother syndrome does not rise to the surface in this type of a wellness initiative or screening,” he says. “We can provide the community or the employer with sanitized, aggregate informa tion that does not identify down to an indi vidual level, but can identify the chief parameters of wellness or disease condition within the community being screened. Of course, we also can allow the individual or his caregiver the ability to see both his present condition at the time of an assessment as well as his relative improvement over time. That is a tremendously valuable tool that previ ously was done by gathering a lot of paper intensive reports.” The diseasemanagement industry has taken privacy concerns into account. Accord ing to a white paper published by the DMAA, The U.S. Department of Health and Human Services has fully safeguarded the ability of legitimate diseasemanagement programs to use and disclose protected health information for activities such as enrolling and engaging patients, teaching patient self management, coordinating care, providing medication compliance guidance and reminders, publishing outcomes data, con ducting population management and risk stratification, supporting physicians and the plan of care, and promoting other disease management and population management services central to improving the quality of care and clinical and financial outcomes for patients with chronic diseases. While legitimate information transfer is protected by HIPAA, given recent scrutiny the industry is expected to be wary. 41 PharmaVOICE S e p t e mb e r 2 003 DISEASE management “Disease management is definitely a trend and it will be interesting to see how HIPAA accelerates or decelerates current efforts,” Mr. Rhoades says. “In the near term it could go slower because companies are being very cau tious about how they handle patient informa tion. On the other hand, because the laws were designed to facilitate the transmission of information between appropriate parties in the healthcare system, this should in effect pave the road and make diseasemanagement efforts easier. It is going to take time before the benefits of HIPAA are realized by the industry.” PharmaVoice welcomes comments about this article.Email us at feedback@pharmavoice.com. Experts on this topic ERIC BOLESH.Senior analyst, Cutting Edge Information, Durham,N.C.;Cutting Edge is a business intelligence firm providing primary and secondary research reports. For more information, visit cuttingedgeinfo.com. MICHAEL COUSINS,PH.D.Director,health informatics, Health Management Corp., Richmond,Va.; HMC is a leading health and diseasemanagement company that manages six of the most highcost, highimpact conditions, achieving demonstrable value for national health plans and employers.For more information, visit choosehmc.com. JOHNCOVER.VP, sales; SUSAN RILEY. President and CEO;BARRY ZAJAC. VP, Clinical Informatics, AirLogix, Dallas; AirLogix is a leader in comprehensive respiratory diseasemanagement services with more than 300,000 patient lives managed.For more information, visit airlogix.com. TERRY CROWSON,M.D.Associate medical director, HealthPartners, Minneapolis; HealthPartners is a family of nonprofit Minnesota healthcare organizations focused on improving the health of its members, its patients, and the community.HealthPartners and its related organizations provide healthcare services, insurance, and HMO coverage to nearly 660,000 members.For more information, visit healthpartners.com. ROBERTDRAZEN.President,Access Health Risk Management,Altamonte Springs,Fla.; Access develops effective,clinically accepted healthrisk identification and reduction solutions for public and private clinically accepted healthrisk identification and reduction solutions for public and private employers,government agencies, healthcare organizations,pharmaceutical manufacturers,and individual consumers. For more information,visit accesshrm.com. ALPAZ.CEO,Euro RSCG Life, Marketing Services Group,NewYork;Euro RSCG Life is a fullservice agency dedicated to healthcare advertising,marketing,and communications. For more information,visit beckernet.com. RICHARD PETRUCCI,M.D.VP,chronic case and disease management,Oxford Health Plans Inc.,Trumbull, Conn.; Oxford Health Plans provides health plans to employers and individuals in NewYork,New Jersey, and Connecticut, through its direct salesforce, independent insurance agents, and brokers. For more information, visit oxfordhealth.com. EDWARDRHOADES.SeniorVP,marketing and new business, Catalina Health Resource,St.Louis; Catalina Health Resource,a subsidiary of Catalina Marketing,offers products that enable pharmaceutical companies to reach desired patient populations with behavior based communications,providing meaningful information that educates patients about their medical conditions and medications.For more information, visit catalinahealthresource.com. WARREN E.TODD.Executive director,The Disease Management Association of America,Washington,D.C.;The DMAA is a nonprofit, voluntary membership organization that represents all aspects of the diseasemanagement community.For more information, visit dmaa.org. employers,government agencies,healthcare organizations,pharmaceutical manufacturers, and individual consumers.For more information,visit accesshrm.com. LOUISE GILLIS. Associate VP, Market Measures/Cozint LP, East Hanover,N.J.; Market Measures/Cozint is a NOPWorld Health company,which is a leading supplier of primary research to the global healthcare community.For more information, visit mmiresearch.com. TIM KLAPISH.Executive director of HealthCare Management,GlaxoSmithKline, Philadelphia; GlaxoSmithKline is a researchbased global pharmaceutical company.For more information, visit gsk.com. JIM KNIPPER.President and CEO, J. Knipper and Company Inc., Lakewood,N.J.; J. Knipper is dedicated to providing a wide variety of direct mail, fulfillment, database, teleservices, patient persistency programs,and recall services exclusively for the healthcare industry. For more information, visit knipper.com. DAVID KRAUSE,PH.D.Healthcare consultant and instructor at Marquette University, Milwaukee;Marquette University is a Jesuit university. For more information, visit marquette.edu. RICHARD P. MANSOUR,M.D.Associate clinical professor of medicine,FeistWeiller Cancer Center at Louisiana State University Health Sciences CenterShreveport,Shreveport,La., and chief medical officer, Eclipsys Corp., Boca Raton,Fla.; Eclipsys is a provider of knowledge driven healthcare information solutions. For more information, visit eclipsys.com. RICK MILDE.VP,Access Health Risk Management,Altamonte Springs,Fla.; Access Health Risk Management develops effective,

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