Managed care's health kick (National Managed Health Care Congress)

In the bad old days of HMOs -- still ongoing in many places -- health plans stepped in the middle of medical decisions by declaring what they would and would not pay for. Now in the coming age of consumer-directed health care, employers and others are asking health plans to step in the middle of medical decisions in another way -- by declaring to patients what health decisions they should and should not make.

In a way, what plans are being asked to do is what they said they would do at the dawn of managed care: actually manage care by worrying more about the health and welfare of members and less about nickel-and-diming on cost.

But nickels and dimes -- lots of them -- are steering health plans toward this adjusted role. That's because employers, especially small employers finding the cost of health insurance to be out of reach, are pressing plans to find ways to lower their insurance costs by making their employees healthier, and thus less likely to use their insurance. And with employees increasingly on the hook for medical bills -- between rising insurance rates and higher-deductible health plans -- employers think plans will have a willing audience.

The changing role of health plans was one of many topics related to consumer-directed health care under discussion at May's National Managed Health Care Congress in Washington, D.C., an annual meeting of health plans, businesses, government representatives and others.

At the meeting, plans talked about how they're already adjusting to the demands of employers and consumers by increasing their use of programs such as disease management.

Insurers have turned to disease-management programs largely to outsource services such as case management through an independent company. Insurers say the main goal is to improve quality and health status of members in conjunction with what physicians are doing during routine visits. Employers have grown accustomed to the programs because they hold down costs.

Since 1997, disease-management vendor revenue has grown to an estimated $1.2 billion, compared with an estimated $78 million in 1997 (the earliest figures available), according to Al Lewis, president of the Disease Management Purchasing Consortium International, a group that represents insurers seeking to contract with vendors.

In 2005 there were 129 million people with chronic conditions, a number expected to grow 32% to 171 million in 2030, says the Partnership for Solutions, a research cooperative led by Johns Hopkins University in Baltimore.

Michael Reardon, MD, Cigna Healthcare's senior clinical director of disease management, said the programs offered today are designed better than the ones insurers abandoned nearly a decade ago. Earlier disease-management programs weren't as comprehensive and relied on mailings to communicate with patients. Today's programs have multiple layers, from health education for physicians and patients to telephone- and Web-based communication with patients.

"We have much more data than we had before and we have more avenues to engage patients," Dr. Reardon said. "The results have been spurring us to do more things."

Eighty-one percent of workers with job-based coverage are in a health plan that uses case management for large claims. Fifty-six percent of insured workers are in a plan with at least one disease-management program, according to the Kaiser Foundation 2005 Health Benefits Annual Survey.

While in some corners there's been doctor support for anything that helps improve the health of patients, there's skepticism about whether health plans are really the best ones to be pushing and running disease-management or other wellness programs.

If the concept of consumer-driven health care is based on allowing the patient to make more decisions, then medical-management programs compliment that goal because they seek to align patients in the most cost-effective treatment settings, said Minalkumar Patel, MD, MPH, president and chief operating officer of Horizon Healthcare of New York, a division of Horizon Blue Cross Blue Shield of New Jersey

Dr. Patel said the system would work better, though, if disease management was handled at the physician and hospital level instead of being dictated from the insurance company. He said insurance plans have been paying for disease-management programs because the infrastructure isn't in place for hospitals and doctors to oversee the programs.

"The delivery system knows the patient better than the insurance system knows the patient," Dr. Patel said. "In the long run it would be better if the delivery system did the disease management and the health plans figured out how to pay for it."

But Steve Ryan, president of Maine Network for Health, a physician-hospital network based in Bangor, Maine, said the efforts by insurers and employers to get people more interested in their health can only help the physician-patient relationship. Ryan said physicians must now prepare themselves for patients who will show up to routine office visits with more knowledge and questions about their health.

"It's important to [physicians] because it does influence how patients arrive at the front door," Ryan said. "The whole relationship is changed because of the idea of an activated patient.

"It can be very positive, but most doctor's offices are being taken by surprise."