Monday, January 16, 2012

Is Disease Management Dead?

Archelle Georgiou thinks so. Her very well-written post (on her own blog here and on Managed Care magazine here) is a thoughtful obituary. She puts the time of death last November, when the New England Journal published Nancy McCall and Jerry Cromwell's report on the CMS disease management pilot program (N Engl J Med 2011; 365:1704-1712). The various DM programs showed little or no benefit, but they cost CMS $400 million. Yes, I agree: disease management, as we know it, has bought the farm and ought to be buried.

Dr. Georgiou offers several quite cogent reasons for DM's failure. The most compelling is that DM as implemented has drifted from the format and target audience originally proven effective in clinical trials in the 1990's. Again, I think she is spot on.

What should we do to improve outcomes and reduce costs going forward? Many of the ideas being proposed appear promising, but have less of a justification than the currently-employed versions of DM have. We just wasted billions of dollars and many years by failing to use the evidence base correctly. It doesn't seem wise to me to abandon the requirement for solid evidence before we invest again. Rather, we should take steps to ensure that we use technologies and programs that are evidence-based AND that we employ them as close to tested as possible.

What are those technologies and programs? Classic disease management for heart failure patients has been proven effective many times and should be retained. Use of automatic systems to support chronic disease patients (and their providers) are very low cost and have also been proven in large randomized studies. Lowering co-pays and barriers to access for essential medications and services is another strategy with a large evidence base.

Let's not throw out the evidence-based baby with the DM bathwater.