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Lessons from First-Generation Disease Management Programs
Early programs fell short of their promise, while health care costs continued to grow

By Erin M. O’Connor, Esq., Cammack LaRhette Consulting  9/22/2011

The reluctance of employers to intervene in employee health and lifestyle choices has dissipated over recent years and been replaced by debate on how best to drive healthy behaviors. Early programs generally have fallen short of their promise, while the burden of health care costs has continued to grow. These strategic failures have resulted in critical insights that will inform the next generation of initiatives.

What Doesn’t Work

The traditional approach to disease management—one of the pillars of employee health programs—is largely patient-focused and involves phone calls by nurses and other professionals to health plan members diagnosed with a “big five” chronic disease: coronary artery disease, diabetes, chronic obstructive pulmonary disease, asthma and heart failure. The prevailing approach is to prevent exacerbations and complications by using evidenced-based practice guidelines and patient empowerment strategies. Some fundamental shortcomings of this approach are:

1. Identification of high-risk members

Algorithms for selecting patients often rely on historical information, such as members with the highest health care costs. By the time those members are targeted, they have undergone treatment.

Selection criteria that depend primarily on medical and prescription claims identify members with well-established chronic conditions and miss early-detection opportunities.

Targeting specific chronic diseases might lead to providing care in disease silos. Frequently, patients have co-morbidities that require a whole-person approach.

2. Call center model

Telephonic coaching is conducted from call centers or other remote locations. Attempts to familiarize nurses with account-specific information are hampered by a lack of familiarity with the culture of the community. Similarly, delivery of health care differs from one region to another. Distance inhibits coaches’ establishment of trust and rapport with members and physicians.

3. Member-centric focus

Traditional disease management focuses on member self-care. With the plethora of credible health content available online and from various sources, the issue is not necessarily an information gap but the need for a more coordinated health care effort. For example, the physician plays a critical role in promoting behavior change. Additionally, the health plan sponsor may need to address access barriers such as deductibles and co-pays for preferred programs or provider network restrictions.

Telltale Signs of Ineffective Programs

Self-insured and fully insured employers might be paying for nonperforming programs. Even a sophisticated health care system can be surprised by poor performance. In one instance, the health plan had inadvertently turned off the data feed to the disease management vendor. No new members were added to the program for six months, but no one noticed.

Red flags signaling potential problems with a disease management program include the following:

1. Simplistic engagement metrics

Substantive engagement with a coach is required in order to change behavior. The number of postcards sent to members should not count as engagement. Nor does one call with a coach suffice. Engagement begins when the employee participates actively (for example, agrees to a second call with the coach or requests print or online materials).

At least two to three coaching sessions are necessary to gauge whether the coaches are being accepted and/or getting to the right people.

2. No physician collaboration or provider referrals

Hourly invoices or reports should reflect time spent discussing cases with physicians. Look for at least 20 percent of the time to be spent with physicians. Customer-centric vendors should be able to provide this information.

Reports should include referral counts. Coaches who know the community resources will encourage participation in health and wellness resources—such as employee assistance programs (EAPs) and Weight Watchers—that provide support.

3. Few anecdotal reports from employees

In our experience delighted employees come forward to discuss their experiences, notwithstanding the rigorous privacy protections afforded to individuals. If employer representatives do not hear any success stories, it might be that there are none.

4. Inconclusive results

Disease management vendors should calculate results and provide details on their methodology—including benchmarks and references for the standards used.

Erin M. O'Connor is the health care consulting practice leader at Cammack LaRhette Consulting. She has developed engagement and communications programs targeting physicians, organizational leadership and employees. She is currently leading engagements to integrate health and productivity management in several health care systems in the Northeast.

Related Articles: 

Viewpoint: Avoiding the Chronic Disease Cost Avalanche, SHRM Online Benefits Discipline, September 2011

Integrated Disability Management in a Challenging Economy, SHRM Online Benefits Discipline, March 2011

Disease Management Info via Online Groups Not Always Accurate, SHRM Online Benefits Discipline, November 2010

Managing Diabetes: Incentives and 'Coaches' Improved Health, Lowered Costs, SHRM Online Benefits Discipline, May 2009

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