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Healthcare IT advances are pulling together to manage an expanding universe.

The face of disease management changed for good in late 2003. When the Medicare Modernization Act became law, so did its interleaved self-edict to create the Chronic Care Improvement Program (CCIP), one of the most influential votes for quality-based disease management ever to come from traditional fee-for-service Medicare. CCIP, operated under the auspices of the Centers for Medicare & Medicaid Services (CMS), will transform the way healthcare providers and payers view disease management--starting now.

CCIP is a hefty vote for quality in chronic-disease care, explains Christobel Selecky, president of the Disease Management Association of America (DMAA), Washington, D.C., and CEO of LifeMasters Supported SelfCare Inc., Irvine, Calif. "Medicare historically has driven a lot of change in how providers are compensated and how benefits are structured," she says. "To have CMS take this step and say, 'in a very large-scale, scientific way, we're going to evaluate disease management approaches and diseasemanagement in populations of fee-for-service Medicare beneficiaries' means they're going to answer the question, 'does disease management really work?'"

Early in 2004, CCIP offered funding by way of grants to 10 disease-management projects for three years of controlled monitoring. Applicants for these Phase I demonstration project grants were asked to propose programs combining patient education, behavioral-change initiatives and clinical care regimens that would help providers, patients and payers achieve the long-term goals of chronic care. Programs were to target congestive heart failure (CHF) or diabetes with co-morbidities, two of the most expensive chronic conditions under Medicare. 
Shifting sands: The payers
Nearly everyone agrees that, in concept, disease management should work, and the CCIP program may encourage payers and providers to fast-track their disease management leanings. Traditionally, payers have focused on the five chronic diseases considered most costly--pulmonary disease, CHF, asthma, diabetes and end-stage renal disease. But now, Selecky says, payers are beginning to look ahead to conditions that might cost them big bucks later on, like hypertension and obesity.

Disease management was never meant to be limited to the costliest chronic diseases, says Erica Drazen, vice president of emerging practices, First Consulting Group, Long Beach, Calif. And some of those "lesser" conditions are encroaching quickly; obesity might soon become number 6. Hartford, Conn.-based Aetna; Horizon Blue Cross Blue Shield of New Jersey (BCBS-NJ), Newark; and others have launched programs on obesity.

A weight management outreach program that Horizon BCBS-NJ piloted in 150 New Jersey schools in October already has a waiting list. New attention also is going to co-morbid conditions, such as pain and depression, that often accompany chronic diseases. And payers are beginning to link their disease management programs instead of classifying diseases as separate conditions. Horizon BCBS-NJ added multiple sclerosis and hepatitis C programs in 2004, with depression, cancer and pain-management programs coming in 2005.

Aetna is looking at the role of ethnicity and culture within its overall insured demographics. Its initiatives to reduce ethnic disparities in disease management service, including in African-American pregnancy and Latina breast health awareness, earned Aetna the 2004 Health Plan Leadership award from DMAA.

The approach to disease management is becoming much more holistic, says Cheryl Pegus, M.D., M.P.H., Aetna's national medical director for women's health and clinical programs. "We're addressing issues long before you have a chronic medical condition, based on what we know of how you're using the healthcare system."

Many also predict shifts in reimbursement models. Testing the waters with group employers, payers are developing creative incentives to promote patient behavior change, notes Christopher Valerian, D.O., senior medical director of health affairs, Horizon BCBS-NJ. One of Horizon's group employers is offering cash incentives to diabetic patients who fulfill the nationally accepted diabetes testing guidelines. Other clients are trying the opposite method, in which patients who receive a premium discount for joining a disease management program can lose that discount for noncompliance.

But payers are still working to show providers what's in it for them, Valerian says. When payers first developed their disease management programs, providers were excluded purposely, "but as the programs became more comprehensive, everyone realized that if you have the providers on board, it makes life a lot easier and a more collaborative effort," he says.

Disparate data
In the past, when it came to identifying high-risk patients, payers and providers each had select pieces of data, but neither had the complete health puzzle. Predictive modeling tools, commonly used by payers for risk stratification, tapped into claims and pharmacy data and utilization rates but not the rest of patients' medical records or lifestyle information, Drazen says. Primary care physicians, who might see patients only a few times per year, usually spent office visits treating illness instead of promoting wellness.

Some providers tagged patient charts for certain chronic diseases, but such initiatives tended to fall apart if patients failed to return for needed tests. These days, more providers are running disease management programs using computerized patient registries, which contain patient-service checklists and sometimes provide electronic alerts on patients who are overdue for tests or services. But many physicians cannot afford the IT investments, notes DMAA's Selecky. "I'm a huge proponent that disease management should be done at the provider level," she says. But "most providers operate in small environments where they don't have sophisticated technology to do the database analysis, predictive modeling and risk stratification."

The industry is in transition, though, she says, adding, "The questions are, how can we make that [technology] available at the provider level, and how do we incentivize providers to use those systems?"

The new view: Collaborative design
As always, conjoined program efforts are the ones to watch. The Duke Prospective Health program through PrimaHealth IPA, Durham, N.C., has approached chronic disease management as a deep collaboration among provider, patient and health plan--earning it the 2004 Provider Engagement Initiative award from DMAA. The program combined a 31,000-patient base with clinical teams, disease management guidelines and IT to help engage patients in their own better health, explains Peter Jacobi, M.D., medical director of PrimaHealth and the Duke program. Incentives were used at every step: Patients received a $25 grocery coupon just for agreeing to a healthrisk assessment.
Those falling into a high-risk category on the basis of hypertension, obesity, elevated lipid levels, tobacco use, and/or diabetes received an additional incentive--$100 toward medication costs--if they agreed to work with a care manager for at least 90 days.

Patients registered in the program have a computerized portfolio that includes their risk assessment, goals, guidelines and reminders for regular testing. Soon, the system will also integrate clinical outcomes, lab data and reminders for wellness services, such as mammography.

Physicians also receive incentives, which now are based on the number of patients registered in the program but later could involve patient outcomes (e.g., improved lab results), Jacobi says. Close attention among physicians to the health plan's goals was vital to the program's success, according to Jacobi. "Most [other] disease management programs are aimed directly at the patient, and the clinical team is just along for the ride."

If we build it, will someone pay?
The long-standing complaint among providers has been that robust disease management requires proactive communication tools and a hefty amount of provider time--time that doesn't necessarily fall under a handy billing code.

Charles Kilo, M.D., M.P.H., and CEO of GreenField Health, near Portland, Ore., admits that healthcare's visit-driven system doesn't give physicians enough incentives for wellness maintenance. "We're paid for cranking through patients," he says ruefully. "We're paid for the hamster wheel."

GreenField's five-physician clinic built a patient registry for its Logician EMR, a system now marketed by Waukesha, Wis.-based GE Healthcare's Centricity line. The registry maintains patient lists for various disease-condition indicators, such as hypertension and elevated lipid levels. Physicians and care managers communicate often with patients, including by email, Kilo notes.
Not all primary care facilities can afford such a holistic approach, he acknowledges.

"When push comes to shove, hospitals and large healthcare organizations are financial entities. Finances will trump quality every single day," Kilo says. "Until the dynamic changes of how care is organized, until we stop getting paid for defects--i.e., the sicker people are, the more we get paid--we'll be stuck in this conundrum."

Geisinger Health System, Danville, Pa., took on pushing change, one payer at a time, after it launched its aggressive osteoporosis intervention program in 1996. To justify bonedensity screening and diagnostic testing prior to disease diagnosis, and in patients younger than age 65, providers and payers forged reimbursement agreements and some special billing codes, explains Eric Newman, M.D., Geisinger's director of rheumatology and chairman of the osteoporosis program. Adding a multipayer code grid to the system reduced billing rejections; clicking on the patient's insurance carrier automatically fills in the pre-arranged code.

Quality rewards
National attitudes about quality are shifting. CCIP sets a precedent that chronic care quality should matter--and that quality efforts should be rewarded. "Some very wellintended people are now asking some very hard questions and trying to put forward some innovative programs, and I congratulate that," says GreenField's Kilo.

"Unfortunately, the skeptics will say that what the average primary care practice [gains] from it is not going to be enough to overcome the financial barriers to do it, to purchase and use the technology. So there are pros and cons." But providers may be more willing to step forward now, adds Geisinger's Newman: "Before the demonstration projects, the incentives weren't aligned with the outcomes you wanted to achieve. Now, this is a first step in saying, 'if you provide best care and save money along the way, we'll allow you to keep some of that.'"

The disease management bar has been raised. And healthcare institutions that embrace that change will most likely be viewed as trendsetters for the coming years.

(extraído da publicação Healthcare Informatics, focada no estudo de TICs para Healthcare) Fevereiro 2005