Disease Management

Preventive care programs that proactively attempt to manage chronic disease.

Disease management programs target high prevalence, costly, chronic illnesses that may be effectively managed with a population-based approach (see Figure 16-1). Management of chronic illness between physician visits is an important component of these programs, which typically use nonphysician providers to teach patients self-management and to coordinate care with physician providers.

Carve-outs, case rates, and disease-specific educational programs are sometimes referred to as disease management programs but they are not. With carve-outs, a particular specialty or disease group (eg, mental health) is separated from the contracting model and given to an independent organization or provider group, which becomes responsible for it. Carve-outs for mental health care are common. With case rates, an MCO contracts with a provider for care during an entire episode of illness. This approach is often used for surgical procedures (eg, hip fractures). Finally, programs that are primarily educational are sometimes termed disease management, although they do not actively manage illness.

MCOs often develop disease management programs for classic geriatric problems (eg, heart failure, diabetes, falls, polypharmacy). For example, a typical MCO polypharmacy program includes a direct-to-member and a physician component. Members who use many (eg, >= 5) drugs within a specified time (polypharmacy) are identified through self-reporting or through administrative data obtained from pharmacy records. These members are sent a brown bag with a letter from the MCO medical director describing the risks of taking multiple drugs and asking them to place all their prescription and over-the-counter drugs in the brown bag and take them to their physician. The physician is sent a drug management report that lists and organizes all prescriptions filled by the member, including prescriptions the physician may be unaware of (eg, those obtained from consultants). The report enables the physician to quickly check for drug duplication and drug interactions. Polypharmacy clinical practice guidelines or other educational information (eg, recommendations on improved prescribing) is also sent to the physician. Polypharmacy programs can reduce unnecessary pharmacy costs, improve prescribing, and reduce the number of adverse drug interactions. Occasionally, such programs employ MCO pharmacists to review drug management reports.