Statement of Jonathan T. Lord, M.D., Chief Clinical Strategy and Innovation Officer, Humana Inc.,
 Louisville, Kentucky, and President, Disease Management Association of America

Testimony Before the Subcommittee on Health
of the House Committee on Ways and Means

Hearing on Promoting Disease Management in Medicare

April 16, 2002

Good Afternoon.  My name is Jack Lord, and I am Chief Clinical Strategy and Innovation Officer for Humana Inc., one of the nation’s largest health benefits companies.  Humana provides health benefits to nearly 6 million commercial, military, and Medicare beneficiaries.  I have also spent time as Director of Quality for the Naval Medical Command, Executive Vice-President for a large health system in Maryland, as Chief Operating Officer of the American Hospital Association, and as President of Health Dialog, a company providing tools and services to enhance consumer medical decision making.  Additionally, I am president of the Disease Management Association of America.  I am pleased to be here to tell you about how health benefits companies like Humana have turned to disease management programs to help our members – especially those members most in need of care – to obtain appropriate and effective care. 

Over the past six or seven years, the offering of health benefits has significantly changed to address what consumers want.  Many of those changes are already bearing fruit.  So not only do we have a great chance to exceed the expectations of our customers – they couldn’t be lower – but by the time everybody becomes aware of the great changes that have taken place in our business practices, we will already have results to prove that the new approaches work – not just for us and for employers but for patients, too.  I’m happy to be here to share some of these results and, more importantly, some of these success stories, with you today.

First, I’d like to tell you a little bit about how health plans have begun to focus on disease management as a core strategy for addressing medical management.   Then, I’ll share with you some information about disease management programs – what they are, how effective they are, and what we do at Humana , as a health plan, to better target, recruit, and triage our members, and to provide better continuity and integration of care.  Finally, I’d like to talk a little bit about how disease management can be extended to all Medicare beneficiaries, and note some practical obstacles that may stand in the way.

New Approaches to Medical Management

Consumers in the market place have made health plans to look in the mirror and rethink how they approach medical management.  Humana, like many other plans, has made extensive changes in its approach.  We are trying to focus our effort on providing personalized support to the sick so they can get appropriate care and provide opportunity for the healthy to manage their own health with the help of advanced information technology.   We take seriously our relationship with our members and our responsibility to help them get more control and make better decisions about their health and their care.

Our data show that a relatively small percentage of members consume the health care services that account for 90 percent of health care costs each year.  Medicare knows this phenomenon well.  In the Medicare population these tend to be very sick people with chronic conditions that require ongoing attention if they are not going to enter a cycle of costly acute episodes, or beneficiaries at the end of their lives.

Think, for a moment, about the people you know with serious chronic diseases – people with diabetes, heart disease, or kidney disease.  These people need to receive routine care for their conditions, adhere to treatment protocols, comply with medication regimens. And if they do, their conditions can be maintained and their health functioning significantly improved.   For many of the most common and costly conditions, programs have been developed to operationalize the clinical knowledge that will keep these chronically ill people feeling relatively healthy, keep them out of the hospital and reduce their health care needs and costs.

These sorts of programs are increasingly prevalent in health plans.  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.

What is disease management?

 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.  They do this by educating the patient and encouraging adherence to a personalized treatment plan based on the body of clinical expertise we call “evidence-based medicine.”

Disease management evolved over the last twenty years out of the recognition that our health care system does not behave like a system at all.   DM is an approach to patient care that is designed to compensate for the fragmentation in service delivery, the unwanted variation in care, the lack of adherence to clinically proven practices, the lack of adequate patient education and decision support, and the inadequate involvement of patients in making decisions about their care. 

Disease management is a multi-disciplinary set of services that generally involves identifying the population at risk and eligible for disease management services, and matching interventions with need;  educating patients for self-management, including primary prevention, behavior modification, and support for compliance with the treatment plan;  ongoing, structured assessment and the use of evidence-based practice guidelines to establish personalized treatment goals and to standardize treatment plans; ongoing communication with the patient and her family, with routine reporting and feedback to her physicians and support-service providers; measuring, evaluating, and managing outcomes;  and periodic reassessment and feedback to capture problems as early as possible and to make adjustments to treatment goals and care plans before the problems become more severe.

For many patients the need for health care is ongoing and the required patient effort is significant.  Intensifying the support provided to those patients and their practitioners can improve the process and outcomes of care.   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.    Since most physicians practice alone or in small, single-specialty groups without an infrastructure or team to support the systematic management of patients with chronic disease, DM programs emphasize the coordination of services between the treating physician and nurse case managers, educators, pharmacists and other health care professionals.   Because of the need for daily monitoring of measures of health or adequacy of medication, such as blood sugar in diabetes or body weight in congestive heart failure, patients with chronic illness need to take an active role in the management of their disease.  Advanced information technology is frequently used to monitor patients, such as Interactive Voice Response (IVR) systems that allow patients to make daily reports of their vital signs and symptoms using a touch-tone telephone, facilitating regular reporting of process and outcome indicators.

By maximizing patient adherence to prescribed treatments and to health-promoting behaviors, patients with chronic diseases should experience better clinical outcomes, better functional capacity and quality of life, better access to care, better coordinated care, and lower health care costs through a reduction in hospitalization, surgery or other invasive care. 

Effectiveness of Disease Management

So what does the research say?  How effective are these programs? 

A study of a diabetes program implemented in several plans concluded that the program generated substantial cost savings and resulted in substantial improvement in all clinical measures.  According to the study, “members were more likely to receive HbA1c tests, foot exams, eye exams, and cholesterol screenings while enrolled in the program . . . [and h]ospital utilization decreased dramatically for each plan’s diabetic population.” [1]   Another study that followed a group of  patients with congestive heart failure showed significant improvements a year after enrollment, including a 48 percent reduction in inpatient (acute) days, a 36 percent reduction in inpatient admissions, a 31 percent decrease in ER visits, and a 20 percent decline of average length of stay, yielding an average reduction in disease-specific claims of 54 percent and total claims of 42 percent. [2]   Health status improved, too – surveys revealed a 16 percent improvement in functional status and quality of life, as reported by patients themselves.

Our own experience mirrors these results.  We have found significant savings related to the investment in time and support to help the sickest of our members.  But more importantly, we have seen significantly improved health results for the members.  Ninety percent of participants in our CHF program show stabilized or improved disease status, with a 60 percent reduction in hospitalization.  Participants in our coronary artery disease program show improved cholesterol control.  And a recently published study of our End Stage Renal Disease program, comparing its results against the U.S. Renal Data System, a national registry of 300,000 ESRD patients coordinated by CMS, found significantly higher percentages of Humana members met their dialysis adequacy targets than the national average.  Hospital bed days were 45 percent lower than the USRDS average and  ER visits dropped 75 percent over the two year study period. Mortality for the Humana population was 80 percent of the expected mortality compared to the USRDS standard.   

Of course, financial results tell only a small part of the tale.  The financial results improve because 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.  Let me tell you a few of these stories.

Mrs. V. is an obese diabetic female enrolled in the CHF program.  At the time of admission, she exhibited moderate fatigue and shortness of breath with exertion.  Her treatment plan focused on weight control, exercise, and maintenance of a low-sodium diet.  Mrs. V. eventually came to exercise four times a day at 45 minutes per day, moderated her salt intake, and lost 60 lbs.  She is very satisfied with the program and looks forward to the regularly scheduled calls.  Mrs. B is a woman with coronary artery disease enrolled after an angioplasty.  She required consistent reinforcement with routine exercise and stress management.  At enrollment, she couldn’t walk a one block without complaining of fatigue, but after one month she is able to walk a mile without fatigue, feels less stress and is more motivated to manage her health.

One of the keys to a successful program is targeting the interventions to the right patients so that services are matched to needs. At Humana, we use our extensive claims information, including daily feeds of pharmacy data, to identify and link members with relevant information and services.  To improve enrollment in our DM programs, we used pharmacy and claims data to identify those members who were likely to have a diagnosis of a chronic disease for which we had an established disease management program. We were then able to compare program enrollment with disease incidence so we could improve the targeting of our efforts to recruit people into the programs.  We subsequently broadened our eligibility criteria and initiated new procedures for the identification and recruitment of individuals who would most benefit from DM services. 

In addition, Humana has implemented a “Personal Nurse” program that reaches out to members during acute episodes of illness.  The personal nurse provides pre- and post-hospital care coordination, coaching and navigational support to help members make their treatment choices, referral into appropriate disease management programs, consultations with a pharmacist for drug-related issues, and access to interactive, on-line personal health tools. 

In this regard, the Medicare + Choice plans have capabilities that Medicare simply does not have.  We have procedures that enable us to identify members as soon as they enter a hospital, which, in Humana’s case, triggers an outbound contact from a Personal Nurse who can assess the member’s suitability for a disease management program and recruit the member directly into an appropriate program.  In addition, the freshness of our pharmacy reports provide a rich source of information about the member’s condition, compliance, complications, and comorbidities, which we can use to identify members for intervention, track guideline compliance, and enable our pharmacy consultants to evaluate possible drug treatment problems.  

Extending Disease Management to the FFS Population

At the moment, these great advantages for the care planning and support for chronically ill beneficiaries are available only to Medicare + Choice members.  However, these represent a relatively small percentage of Medicare beneficiaries.   Most beneficiaries continue to receive their care in the fragmented, uncoordinated fee-for service world.  We continue to believe that the “system-ness” offered through Medicare + Choice plans creates distinct advantages for the prompt identification and recruitment of beneficiaries into appropriate disease management programs.

However, we commend the efforts of the Medicare program to experiment with the use of disease management and  care management programs in the FFS environment and encourage further demonstrations of its effectiveness.   With appropriate targeting and recruitment, free-standing disease management programs can produce savings for the Medicare program and, through the systematization, care coordination, and access to best-practice medicine that is at the core of DM programs, improve the care experience of Medicare beneficiaries.  CMS Administrator Sculley has signaled his intention to conduct more demonstration projects to use private disease management services to bring some of the benefits of managed care to the fee-for-service beneficiaries still struggling to navigate the fragmented, uncoordinated health care “system.”  We think these demonstrations are worth expanding.   In the coming years, with the advancing age of the baby boomers and the increased ability of our health system to keep them alive with chronic illnesses, the number of Medicare beneficiaries having to manage chronic health conditions is likely to rise.  There are clearly some obstacles to the implementation of DM in the Medicare FFS population that will  require some creative solutions.   The most important of these is the identification and recruitment of the most suitable beneficiaries during their moments of acute need – mechanisms that exist within M + C plans to identify people when they are first entering an episode of acute illness do not currently exist.  In addition, Medicare cannot rely on claims information for the identification of eligible beneficiaries unless it is very timely.  These problems are not insurmountable, but they do need to be addressed.

Conclusion

Disease Management offers significant advantages for the chronically ill Medicare beneficiary.  Most Medicare + Choice plans will offer DM services and should be supported for doing so.  But for the many beneficiaries who are not able to obtain coverage in a M+C plan, further extending the demonstrations to make private sector DM services available would be very desirable.

[1] Robert J. Rubin et al., Clinical and Economic Impact of Implementing a Comprehensive Diabetes Management Program in Managed Care, 83 J. Clin. Endocrinol. and Metab. 2635, 2640 (1998) (Attachment B).

[2] Am Heart J 1999;138: 633-40.