Disease Management - COPD

In today’s Disease Management (DM) segment, I am focusing on Chronic Obstructive Pulmonary Disease (COPD), one of the six top diseases or entities to manage with a DM Program in the Medicare (over age 65) population:

Burden of illness and rationale for a COPD Disease Management program

COPD affects over 15 million Americans and is the third highest cause of death, responsible for killing over 120,000 patients annually.  Almost all cases of COPD are caused by cigarette smoking.  Because of its high prevalence, chronicity affecting patients for many years, and high morbidity and mortality, COPD is an excellent disease for a high-functioning DM program to manage.

Confirming the diagnosis of COPD correctly allows for appropriate management of patient symptoms and co-morbidities, such as vascular disease and other respiratory conditions such as bronchitis and pneumonia.  Correct management of patients with COPD reduces symptoms, as well as reducing the severity and frequency of exacerbations.  Correct management also improves patients’ quality of life, exercise capacity, and prolongs survival.

As with all effective DM programs, a high functioning COPD program takes work away from the doctor and adds a safety net under the patients to prevent important gaps in care.

How does a COPD DM program work?

As in all DM programs, step 1 is correctly identifying patients with COPD.  This process can be accomplished via a combination of analyzing claims coded for COPD and looking for evidence of spirometry (a standard breathing test) with a below normal result.  The usual DM process of vetting algorithmically derived lists of likely patients with COPD with the provider’s knowledge of the patients ultimately helps produce the most accurate list or registry of COPD patients.

Once the registry is established, each individual patient is bumped up against a list of required or advised measures, including:

  • spirometry testing
  • influenza and pneumococcal vaccine
  • correct use of inhalers
  • understanding of warning signs for exacerbation
  • correct use of supplemental oxygen if indicated
  • smoking cessation counseling if indicated

The registry also helps to assure that patients with COPD are evaluated at least twice yearly by their provider team.  It is important to note that DM programs are best run by nurses or other staff trained in quality measures, to ensure that all patients on the registry are receiving all required elements of care.  More complex patients may be referred for specialist pulmonology care as needed.

Provider education

A high functioning DM program usually links provider education with patient outreach.  At times, doctors and other providers lose touch with the latest advances in medicine, and some targeted educational sessions with providers about their own patients taught by a local engaged pulmonologist can enhance the outcome of the program.  In these locally run sessions, providers can also provide important feedback to the specialist and/or Medical Director running the program about the overall content and functioning of the COPD DM program.


COPD takes a tremendous toll on patients and their families.  But, when this disease is well managed, the quality of life goes up and the medical utilization goes down.  A well run DM program — as always dependent on high quality claims and EHR data — can facilitate the best possible care of this vulnerable population.

Dr. Rich Parker - Arcadia's Chief Medical Officer

Dr. Richard Parker

Dr. Parker serves as chief medical officer for Arcadia with overall responsibility for the design and implementation of clinical strategies, input into the roadmap and development of Arcadia’s technology and service programs, thought leadership in support of providers transitioning to value-based care, and strategic advisory work for physician leaders at Arcadia’s clients.

Previously, Dr. Parker was an internist with a 30-year history at Beth Israel Deaconess Medical Center. From 2001 until 2015, Dr. Parker served as the medical director and chief medical officer for the 2,200 doctor Beth Israel Deaconess Care Organization. He oversaw the physician network evolve from a fee-for-service payment system to a nationally recognized global payment pioneer Accountable Care Organization. Dr. Parker’s other areas of expertise include end of life care, medical malpractice, care of the mentally ill, electronic medical records, and population health management. Dr. Parker served as assistant professor of medicine at Harvard Medical School. Dr. Parker graduated from Harvard College in 1978, and the Dartmouth-Brown Program in Medicine in 1985.

Dr. Parker is an in-demand speaker to associations, companies, and academic institutions on the topics of population health management, electronic health records, value-based care, and evolutionary, medical and business impacts of stress.

December 9, 2016

Disease Management Programs for Chronic Kidney Disease

In a previous post in this series, Dr. Parker explained the value of a disease management program for chronic kidney disease (CKD), which takes a huge toll on individual patients, their families and the healthcare budget.  Every year, 87,000 patients die of kidney related causes, and we spend over $48 billion per year on CKD.

CKD is challenging to manage because it is a “silent” disease, where patients remain asymptomatic until kidney function has deteriorated to the point where dialysis – or transplant – is needed.  Dr. Parker explains how practices can identify patients who may be at risk and manage them accordingly.

Read the article