Health care providers are beginning to feel the effects of the aging baby boomer population. Aging inevitably brings a higher incidence
of chronic diseases, such as diabetes, hypertension, heart disease, asthma, and osteoporosis – diseases that are often long-lived and very
expensive to control. The Center for Disease Control (CDC) estimates that the medical costs for the 25 million people in this country
with chronic diseases account for more than 70 percent of the nation’s total medical costs. Those numbers are expected to swell as more
baby boomers enter their senior years.
Employers are feeling the pinch of this aging population in increased premium costs, not to mention the price paid for
increased sick days and decreased productivity.
One way to control these costs is through disease management says Marc Rivo, M.D., corporate medical director for Health Services
Research and Innovation at AvMed Health Plans.
“Disease management can reduce the probability of expensive and avoidable emergency room visits or hospitalizations by helping patients adhere to their prescribed care.”
Smart Business spoke with Rivo about how disease management programs can improve health, avoid costly hospitalizations and, ultimately, save employers money in premiums.
What is the first step in controlling the cost of diseases?
The first step starts with employees becoming more informed consumers — both about their conditions and health care choices
and costs. As employees are increasingly shouldering the costs for their premiums, it is to their benefit to become knowledgeable
about options. This may become easier with recent federal legislation requiring increased transparency for price and quality of health
procedures. (Readers can get more information about this legislation on the Web at: hhs.gov/transparency.)
At the moment, the major problem for people with chronic diseases is that people receive only half of the recommended services, such
as laboratory tests and medications, for their condition — and I’m talking about people who have medical insurance and access to physicians. This problem is with our fragmented health care system.
Shouldn’t doctors be guiding patients on how to manage their diseases?
Yes, but oftentimes physicians do not know who else may be caring for their patient. For example, a person goes to the hospital for
a complaint and is newly diagnosed with diabetes. Laboratory tests are run and the patient is placed on new medications. However,
none of this is communicated with the person’s doctor in the community, and the medical records are not transferred. This causes a
whole host of problems for the patient, who may not receive the proper follow-up care. Unless the patient tells his or her doctor, the
physician may not be aware that a patient is on a certain medications, or even has a disease.
What is being done to solve this problem?
Health plans are at the forefront of innovative solutions to this problem through disease management. We do not assume that physicians have all the relevant health information on their patient’s condition. Our goal is to provide that information and help physicians in
their efforts to provide their patients the recommended care.
How does this work?
A health plan uses the information we receive from our doctors and other providers to identify care opportunities. For example, that
newly diagnosed diabetic patient should be periodically screened for kidney and eye complications, among other steps, to ensure that
the disease is under control.
A member who has opted for a disease management program will be reminded that he should be receiving certain recommended
services. The member’s physician is also informed. The goal of disease management is to ensure that we increase from 50 percent
to 80 percent of recommended services provided by their physician.
What are the savings for the employer in having a disease management program in place with its health plan provider?
When people get the recommended physician visits, laboratory exams and medications, they may avoid medical complications resulting in emergency room and hospital visits.
Savings depend on the condition. For example, every $1 spent on disease management programs for patients who are predisposed to
congestive heart failure saves $5 in avoidable hospitalizations and ER visits. For other conditions, savings are ‘soft’ and not easy to quantify. But employers and employees understand that when our medical conditions are controlled, we tend to feel better and are more productive at work.
MARC RIVO, M.D., is the corporate medical director for Health Services Research and Innovation for AvMed Health Plans (www.avmed.org ). Reach him at [email protected] or (305) 671-7327.
