Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 108Disease Management Version 3.0Medical Management GuideMTFs have implemented the clinical practiceguidelines (CPGs) established by the Departmentof Veterans Affairs (VA) and the DoD for numeroushigh-cost and high-volume conditions, includingdiabetes and asthma. However, significant gaps inquality still exist for conditions covered by theseCPGs, requiring further emphasis and continuedevaluation.Employer-Funded Health PlansEmployer funding of healthcare plans has been adriving force in civilian DM efforts, as employersseek to control healthcare program costs.According to a study in the American Journal ofManaged Care (Welch et. al., 2002), DM programswere most likely to focus on three main diseases:diabetes, asthma, and congestive heart failure. Thestudy found that medical directors perceived theirDM programs to be highly effective not only inreducing mortality and morbidity and improving thefunctional status of patients, but also in loweringcosts. This highlighted the need for DM programsto undergo critical evaluation for quality and costeffectiveness. In a survey by the Kaiser FamilyFoundation (KFF) and the Health Research andEducational Trust, 55 percent of large employers(those with 200 or more employees) offering healthbenefits included one or more DM programs. Thesame survey found that 62 percent of large firmshad one or more wellness programs, including injuryprevention, fitness, smoking cessation, and weightloss (KFF, 2006).A report by America’s Health Insurance Plans (AHIP)examined a variety of civilian health programs aimedat improving the quality of life for members withchronic disease (AHIP, 2007). Important trends inchronic care included:• Providing health coaching for behavior change:Healthcare professionals, usually nurses or healthpromotion staff, coach high-risk members onlifestyle changes.• Harnessing advancements in informationtechnology (IT): Technology, such as electronicmedical records and electronic registries, is usedto improve effective care.• Caring for the whole person: Rather thantargeting individual diseases (such as oneprogram for asthma, one for diabetes, and onefor depression), the needs of the whole personare addressed.• Offering a continuum of care: Health outcomesare improved by the provision of a variety ofservices, ranging from wellness and preventionto acute, chronic, and end-of-life care.Cost Savings for Disease ManagementAs previously discussed, cost control is an importantfocus for DM. Medical expenditures in 2006 forindividuals with one or more chronic diseases totaledabout $1.58 trillion, or 75 percent of total U.S. healthspending (Partnership to Fight Chronic Disease,2008).An analysis on the economic burden of chronicdisease in 2003 demonstrated:• The highest treatment expenditures for chronicdiseases were $64 billion for heart disease,$45.8 billion for mental disorders, and $45.2billion for pulmonary conditions.
Medical Management GuideVersion 3.0Disease ManagementPage 109• Direct costs per person were $3,381 for heartdisease, $1,977 for diabetes, $1,509 for mentaldisorders, and $919 for pulmonary conditions(DeVol, Bedroussian, 2007).As recently as 2003, costs for seven commonchronic diseases, cancer, diabetes, heart disease,hypertension, stroke, mental disorders, andpulmonary conditions, were $277 billion withlost productivity totaling $1.1 trillion (DeVol,Bedroussian, 2007). This lost productivity includedabsenteeism, missed work days, and presenteeism.Presenteeism, defined as being at work but notperforming optimally, was identified as causing thelargest share of lost economic output (Partnership toFight Chronic Disease, 2008).According to the Centers for Disease Control andPrevention (CDC), the approach of focusing onvarious risk factors not only helps prevent chronicdisease; it is cost effective. Reducing cholesterollevels for U.S. adults by 10 percent can reduce thenumber of heart attacks and stroke overall by 30percent. U.S. adults lowered blood pressure andhigh cholesterol during the 1980s, which reducedcosts associated with coronary heart disease byabout 9 percent — from about $240 billion in 1981to about $220 billion in 1990 (CDC, 2009).For Americans with diabetes, foot care examinationsand improved self-care as a result of patienteducation could prevent up to 85 percent ofdiabetes-related amputations. Blood pressurecontrol among people with diabetes reduces therisk of heart disease and stroke by up to 50 percentand the risk of eye, kidney, and nerve diseases byapproximately 33 percent. Blood pressure controlalone for this population can result in a concomitantcost savings of $1,200 over a lifetime for a personwith Type 2 diabetes. In addition, self-managementtraining for diabetics prevents hospitalizations: every$1 invested in training reduces healthcare costs byup to $8.76 (Capital District Physicians’ Health Plan[CDPHP], 2008).DISEASE MANAGEMENT COMPONENTSThere are six essential components to effectiveDM:1. Population identification processes.2. Evidence-based clinical practice guidelines(CPGs) to reduce practice variation and improvecare.3. Collaborative practice models, includingproviders and interdisciplinary healthcare teammembers.4. Patient self-management education.5. Process and outcome measurement, evaluation,and management.6. Feedback and reporting to stakeholders,including patients, the healthcare team, andCommand leadership.Full-service DM programs must include all of theaforementioned elements. Programs not inclusiveof all six components are considered “DM supportservices” (DMAA, 2009).1. Population Identification ProcessesDM begins with a thorough assessment and analysisof the population served by the healthcare system.This assessment includes, at a minimum, knowledge
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