Section III - Disease Management

Overview, Goals, and Philosophy

The purpose of this section is to define disease management (DM), compare and contrast it to case management (CM) and utilization management (UM), discuss evidence-based clinical practice guidelines (CPGs) as one aspect of a successful DM program, describe the implementation of DM programs in the Military Health System (MHS), and provide accreditation and certification information.

Under the medical management (MM) umbrella, DM is the third spoke, with UM and CM being the other main aspects. It should be noted that all components of MM blend together when the concepts are operationalized. The lines of distinction may appear blurry, as these programs must work together to achieve the best benefit for the patient and the organization using the programs.

Providers have long strived to return patients to optimum health. It has only been since the mid-1990’s that DM organizations have formed and disease management arguably became the program of choice for populations of patients (Sprague, 2003). There are several driving forces or healthcare industry indicators influencing the MHS to adopt more robust DM practices. There is strong evidence for health promotion, disease prevention, and condition management both in civilian health care and the MHS. In 2002, between 108 and 125 million people in the United States (U.S.) had at least one chronic disease, such as heart disease, diabetes, asthma, hypertension, or osteoarthritis (AHRQ, 2002; Sprague, 2003). These diseases have severe impact upon the quality of people's lives, significant increase in individual healthcare costs, and the development of conditions that lead to a high rate of morbidity.

Employers' funding of healthcare plans has been a driving force of civilian DM programs. Anxious to control and limit their healthcare program costs, employers have adopted DM programs for their employees. In a July 2002 survey by Hewitt Associates, 76 percent of large employers offered some type of DM program, typically through their health plans (Sprague, 2003). The 2001 annual Industry Survey by the American Association of Health Plans (AAHP) noted the following:

The most common DM programs in health plans are those for diabetes, asthma, and congestive heart failure. Ninety-seven percent of health plans have a DM or chronic care program for diabetes and 86 percent have the same for asthma (AAHP, 2001).

Cost control is another of the driving forces for DM programs. Medical spending for persons with chronic conditions in the U.S. was $510 billion in 2000 and is expected to double by 2020 (Mechanic, 2002). Chronic conditions resulted in $234 billion in lost workplace productivity in 1990 (Mechanic, 2000). A study conducted by the Health Management Corporation (HMC) showed participants in disease/condition management programs had a 29 percent reduction in healthcare expenses while non-participants had a 33 percent increase in expenses. Furthermore, participants in disease/condition management programs experienced a 46 percent reduction in severity of chronic conditions while non-participants experienced a 12 percent increase in severity. This resulted in a ROI of $1.30 for every dollar invested in the disease/condition management program offered in this study.

In their testimony to Congress, Medicare leadership noted that Medicare’s fee-for-service has one advantage over many private plans when it comes to DM. "Unlike private insurers, the Medicare program keeps its enrollees for life; that means efforts to improve the coordination of care can be consistently and continuously applied over a long period, and it also means that the benefits from such efforts will accrue to the program, rather than potentially to some other [payor]" (Rovner, 2003). Approximately 30 percent of military members remain in the service until retirement and become TRICARE for Life (TFL) beneficiaries (Force Readiness and Manpower Information System, 2003). Therefore, the same long-term care coordination and program benefits could be realized in the MHS.

Mark Miller, a member of the Medicare Payment Advisory Commission (MedPAC), told the Senate Special Committee on Aging that prioritizing DM for Medicare is clear from the numbers. "Currently more than three quarters of all Medicare beneficiaries have at least one chronic condition and almost one third have four or more conditions," he said. “And beneficiaries with chronic conditions,” he added, "account for about 80 percent of program spending” (Rovner, 2003).