Statement of RMS Disease Management Inc., McGaw Park, Illinois

RMS Disease Management Inc., an affiliate of Baxter Healthcare Corporation, provides disease management (DM) services for patients with chronic kidney disease.   Founded in 1996, RMS coordinates care for approximately 5,000 patients across the United States.   Clients include regional and national health plans as well as the State of Florida’s Medicaid program.

We strongly support the Subcommittee’s efforts to expand disease management programs in the Medicare fee-for-service (FFS) population.   Disease management has been proven to improve both clinical and economic outcomes while concurrently increasing patient and provider satisfaction.    Applying DM to the FFS population offers the government a singular opportunity to improve the quality of care for Medicare beneficiaries, while also addressing increasingly critical funding issues.

Comprehensive disease management programs directly address the issues raised in the March 2001, Institute of Medicine 2 Report “Crossing the Quality Chasm: A New Health System for the 21^st Century”.   Specifically, DM programs supply the patient centered data, necessary information systems, aligned incentives, and integrated care coordination that the report authors believe are required to close the chasm.

End-stage renal disease provides an ideal opportunity for applying disease management principles due to the characteristics of this population and its care.  These characteristics include:

-    A clearly defined population using the HCFA 2728 form

-    Patients typically have multiple co-morbidities in addition to their renal disease which requires complex care that takes place in a variety of care settings

-    Care delivered is fragmented as a result of multiple physician specialists and allied care professionals working in an uncoordinated manner

-    High annual costs

-    Incomplete capture of patient care data in one medical record file

-    Important need for ongoing patient counseling and education

The RMS program has been designed and implemented to address all of these issues and needs.   RMS uses evidence-based medicine, state-of-the-art information technology, and highly experienced nurses to provide care support for renal patients and their attending physicians 24 hours per day, 7 days a week.   Patients receive education, counseling, and care coordination based on individual care plans created by their physicians.  Physicians receive incremental nursing support and comprehensive patient data that otherwise would not be available to them.  Activities in the field are overseen by board certified nephrologists and a nationally recognized Medical Advisory Board.  

Program results published in the peer-reviewed American Journal of Kidney Diseases, May 2001, showed a 35 percent reduction in hospitalization and 20 percent reduction in mortality for patients whose care was coordinated by RMS.   Emergency room visits have dropped by over 75 percent compared to the pre-program baseline.   Further, self-reported patient and provider satisfaction is also consistently very high.

We believe expanding the availability of disease management to the fee-for-service ESRD population will achieve similar benefits to those that have been obtained in managed care populations.    In its deliberations, we would suggest the Subcommittee consider the following:

1)   Establish high standards for defining disease management programs.   There is widespread variability as to what constitutes “true” disease management.   As a starting point, we propose that the accreditation guidelines established by NCQA be used as a baseline.

2)   Ensure that payment mechanisms for patient categories are properly risk adjusted and funded.   For example, current ESRD AAPCC rates do not fully account for the impact of diabetic status, MSP, and transplant.   This results in wide disparities between the actual cost of care and the AAPCC payments for ESRD patients.

3)   Create payment methodologies that reflect how most disease management organizations are structured.   Unlike managed care organizations, most disease management organizations are not set up to contract with providers or pay claims.

4)   View disease states in their totality.  In the case of chronic kidney disease, costs can be reduced significantly if disease management intervention begins before onset of ESRD and dialysis.   Currently, the care and payment systems are not constructed in a way that captures patients before the emergent need for dialysis.   Therefore, the appropriate patient care and education does not take place, which results in unnecessarily high costs and sub-optimal clinical outcomes.

Again, RMS is strongly supportive of the Subcommittee’s initiative to capture the benefits of disease management for the fee-for-service population and appreciates the opportunity to comment.