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Gaps in accountability impede DM success
Noncompliance, lack of social support are issues
Identifying the gaps in care and accountability and closing those gaps is the key to a successful disease management program, says Alan Muney, MD, MHA, executive vice president and chief medical officer for Oxford Health Plans in Trumbull, CT.
Nobody questions the value of case management programs in helping people better manage their illness from a quality performance or clinical outcome standpoint, Muney says.
However, he contends that gaps in the program are largely responsible for the difficulty health plans have in proving the financial value of case management and disease management programs.
Most health plans do well in the area of case management intervention, Muney says.
But there are gaps when it comes to making sure the sickest members are being cared for by the correct physician, which means a physicians who has the highest performance of treating people with that particular illness, he says.
When Oxford took a close look at barriers to optimal treatment for its members, the plan identified a number of barriers to care.
One gap is in the accountability measures in the system — identifying who is responsible when a member isn’t compliant or doesn’t get better, Muney says.
He cites physician noncompliance with guidelines and poor communication among all parties involved in the member’s care as other gaps in accountability.
For example, a primary care physician refers a patient to a specialist, who treats the patient, but then each physician believes the other one is following up. "The member doesn’t understand what the follow up is supposed to be and, as a result, nothing has happened," he says.
Social issues, such as support for the family or caregiver and assistance with issues such as transportation, also contribute to the accountability gap, Muney says. "We looked at these barriers and decided that we need to have control in our health plan to plug the gaps in accountability."
Oxford has had disease management programs for about nine years.
"We have been doing what most other health plans have done, and that is focus on the strategy of the nurse case manager intervening with the people we defined as the sickest in that disease state," Muney says.
The company has been working to identify the right severity of illness within each disease state where they can make a difference in managing costs.
The health plan’s new focus is to work closely with the sickest patients, those who account for the biggest health care cost, and identify each individual’s barriers to care.
Oxford has approximately 14,000 members in its congestive heart failure program. Of those, 1,200 are designated as the sickest patients. There are 35,000 members identified with diabetes, with 3,400 in the highest-risk category.
"These 4,000 or so members are pretty manageable in terms of case manager interventions, and they are by far driving most of the cost within the disease," Muney says.