Physical Health
Disease management
Disease-management strategies that include healthy lifestyle behaviors, adhering to strict medication regimens, and routine medical assessment and disease monitoring can improve individual health and reduce overall health care costs for some chronic conditions (e.g., diabetes). However, disease management may be complex and difficult for both patients and providers. Behaviors such as physical activity and proper nutrition may be challenging for individuals to maintain over long periods of time. Furthermore, adequate patient education often requires substantial time and money for providers to implement.
Daily medication regimens, routine tests, and treatment regimens required for proper disease management may be too complicated for some patients to handle on a daily basis. Older adults are especially vulnerable to adverse events related to prescription drug misuse. Older adults make up 13 percent of the population, but use almost 36 percent of all prescribed drugs. Approximately 87 percent of older adults take at least one prescription drug a day, along with multiple over-the-counter medications. Physiological changes caused by age increase sensitivity to the effects of medication.
Polypharmacy is also a concern when a patient is taking multiple medications or is inaccurately or over-prescribed medications by multiple health-care providers. Serious adverse events and hospitalization may also arise due to failure to adhere to the proper medication regimen. Medication Management services, such as screening and education to prevent incorrect utilization and adverse drug reactions, are funded by the Older Americans Act and are provided by many of the 28 area agencies on aging in Texas.
Congress has recognized the benefits disease management can have among older adults. At a recent hearing of the Senate Special Committee on Aging, policy makers heard how disease-management programs empower individuals to improve health status and can prevent the complications often associated with chronic diseases. Testimony provided at the hearing also indicated that disease management may reduce overall health care costs.
For example, Medicare beneficiaries who suffer from chronic illnesses such as diabetes, congestive heart failure often undergo repeated and costly hospitalizations. In fact, three-quarters of all Medicare fee-for-service costs can be accounted for by just 12 percent of its beneficiaries. While some of these people are among the frailest and oldest, requiring coordinated, specialized geriatric care, many could avoid repeat hospital visits if enrolled in a disease-management program. Research demonstrates that one dollar spent on diabetes outpatient education (i.e., daily medication regimens, insulin injection, blood glucose monitoring) can save two to three dollars in hospitalization costs. Similarly, participation in an arthritis self-help course can reduce pain an average of 18 percent and saving an average $267 in health care system costs per person over four years.
Texas Medicaid managed care programs (MCOs) are utilizing disease management strategies to approach complex cases. The diseases selected for management vary according to the population served by the HMO, however the majority of disease management efforts in Texas have focused on high-risk pregnancies, diabetes, and pediatric asthma.
In addition to Medicaid Managed Care Organization's internal disease management initiatives, the Texas Health and Human Services Commission has completed the Texas Medicaid Managed Care Diabetes Pilot (SB 162, 75th Legislature), and is in the process of implementing the Texas Medicaid/CHIP Pediatric Asthma pilot (SB 616, HB 342 and Rider 51 of HHSC's Appropriations Act, 77th Legislature). This pilot will operate in six sites across Texas and will include managed care and fee for service health care delivery systems. Disease management programs in Texas have limited enrollment, with the highest number of clients enrolled in the prenatal care program.
The 77th Texas Legislature (SB283) required the HHSC to ensure that contracted managed care organizations (CMO) develop and implement disease management programs to address chronic health conditions, including asthma and diabetes. The bill required HHSC to study the benefits and costs of applying disease management principles in the delivery of Medicaid managed care.
Therefore, HHSC, in partnership with the University of Texas School of Public Health in Houston conducted an analysis of disease management activities in other states, surveys of Texas Medicaid contracted managed care organizations, and conducted focus groups with Medical Directors in managed care organizations and state agencies to understand current activities in Texas, and to formulate a plan for continued implementation and oversight of disease and health condition management programs.
The evaluation addressed effectiveness in reducing long-term health care costs, improving patient care, and improving appropriate health care utilization patterns of recipients. Results of early studies indicate that disease management programs can reduce the high cost of services, improve patient quality of life, and delay the onset of more severe stages of disease. Disease management also has the potential to foster patient self-care, promote patient accountability, continuity of care, improve patient and provider satisfaction, promote efficient use of health care resources and increase productivity. As a result of these findings, HHSC recommendations are to
- modify existing HMO contracts to encourage the use of disease management programs to increase quality health care indicators for certain populations,
- allow HMOs opportunity to demonstrate reasons for choosing not to implement diabetes or asthma specific programs,
- monitor the implementation and operation of disease management programs by HMOs through a survey process on a 2 year cycle,
- use the next HMO procurement process as a method for seeking innovative approaches in disease management, and
- continue to develop and implement disease management pilot projects that incorporate fee-for-service, PCCM and HMO components.
Updated: November 2, 2007
