Insurance companies enlist disease-management firms to assist chronically ill and trim costs, but some docs are skeptical

The Tennessean

Juanita Williams of Madison has a team of nurses to help her manage her congestive heart failure… and it doesn’t cost her a dime.

A cuff and a scale automatically transmit the 76-year-old’s blood pressure and weight to the nurses every day, and the nurses call to check up on her, coach her on healthy eating habits as needed and keep her doctor informed of any blood-pressure or weight changes that might signal a worsening of her condition.

“I just think they’re real nice,” Williams says of the nurses. “And I enjoy talking to them. When they call sometimes it’s strictly business and sometimes we just talk. I think it’s when they’re not busy that we talk.”

The nurses work for Nashville-based American Healthways, which contracts with insurance companies to provide this seemingly warm and fuzzy approach to health care.

Disease-management practices such as these are becoming more common among insurers as they try to create healthier profits by making healthier members. Some doctors and consumer groups are skeptical of the approach, however, and say it can undermine the doctor-patient relationship or make it harder for people to get coverage for chronic diseases.

Teaming up

The term disease management was coined 10 years ago, and the volume of business has boomed in the past few years as the idea has caught on, says Bob Stone, American Healthways’ executive vice president and co-founder.

The company contracts with 22 different health plans nationwide and serves nearly 850,000 members. Just two years ago they had less than half as many members, about 350,000.

Nationally, analysts predict growth in the disease-management industry of about 20% in coming years as the population ages and insurers keep looking for ways to cut costs.

Chronic diseases such as diabetes, heart disease, chronic obstructive pulmonary disease and asthma make up the core of disease-management programs.

What the diseases have in common is that they require lifelong management and account for about half of health-care costs, Stone says.

By keeping these patients as healthy as possible, disease management creates a win-win situation.

“As health conditions improve, savings continue to improve,” says Stone, who also is president of the Disease Management Association of America.

How it works

Approaches to disease management vary, with companies using mailings, the Internet, home-monitoring equipment and direct phone calls to reach patients.

American Healthways initially gives patients a welcome call in which they explain the voluntary program. Despite an occasional “who are you and why are you calling” reaction, the company has a 95%-98% participation rate, says Joanne Russell, executive director of the company’s Cool Springs call center.

Once they become members, a nurse calls them for a 45-minute health assessment. The patient, which the company refers to as a “member,” then selects a regular time to be reached.

The sickest members get a call a minimum of every two weeks; healthier patients get a call three to four times a year. Calls can take anywhere from three minutes to 45 minutes or more.

Patients also can call the nurses if they have questions about their plan of care, although the nurses don’t diagnose conditions.

American Healthways has six call centers nationwide, and the chance of a nurse speaking with the same patient twice is slim. But the nurses keep extensive notes in the members’ file, allowing them to create a rapport and set small goals that, coupled with some “nice nagging,” can help people lead healthier lives, Russell says.

The bottom line

Because disease-management companies such as American Healthways work for insurance companies and not doctors, some are skeptical of their programs.

Nashville clinical endocrinologist Dr. Craig Wierum says disease management has “tremendous potential” to help patients, but he says the advice that disease-management nurses give can conflict with the doctor’s advice.

Disease-management nurses follow standards of care set by organizations such as the American Diabetes Organization, but sometimes a doctor might need to deviate from guidelines based on the individual patient’s needs and circumstances. The conflicting advice confuses patients, who end up calling their doctors, asking them to explain the difference, he says.

American Healthways sends doctors patient updates at least twice a year, but Wierum says the communication between disease-management companies is insufficient and usually is a standard fax.

“It’s never a personalized, ‘Look, we need to talk about Mrs. Jones. We think such and such is happening,’ ” he says.

Although Stone says changing a doctor’s plan of care is something that his company absolutely does not do, Wierum sees an increasing and disturbing boldness on the part of insurance companies.

“Once a year I get a report card from United Healthcare that tells me all the things I failed to do on my patients,” he says. “The report card is notoriously inaccurate . . . 80% of the time you end up pulling your records and defending actions that were appropriate. It just eats up a tremendous amount of time.”

Jerry Flanagan of The Foundation for Taxpayer and Consumer Rights, a California-based advocacy group, says the information insurers collect through disease-management programs might be used as an excuse to deny people coverage if they were to try to change plans. Not complying with the guidelines set by a disease-management program could potentially make someone a candidate for a rate increase.

Because disease management by insurance companies is a relatively new practice, “there’s not a lot of law in this area to make sure that patients are protected,” Flanagan says.

Despite such concerns, Stone says that within the next three to four years, companies likely will begin using predictive computer models to analyze a person’s risk factors for disease and set up programs in which nurses and dietitians encourage people to avoid those risks and stay healthy.

“I think ultimately the industry is going to have to change its name,” he says. “Because, obviously, when we’re working with healthy people, we can’t call it disease management anymore.”
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Sameh Fahmy covers consumer health for The Tennessean. Reach him at 259-8072 or [email protected].