In medical school, doctors learn how to take care of patients one at a time.  But, we are not taught how to care for populations.  The latter is important, because many patients can fall between the cracks of care without a robust disease management program.

Example: a patient with slowly deteriorating kidney disease

For example, a patient with slowly deteriorating kidney disease will not be personally aware of this problem.  Her doctor may also not be aware, unless she is carefully monitoring the kidney function labs – including the serum creatinine and urine protein.  A well-functioning disease management program will pick up the fact that a patient’s creatinine has risen in to the danger zone, automatically triggering an alert to the physician and/or care manager.

At that point, outreach occurs to bring the patient in for a visit to address the problem.  The patient is then entered in to a Chronic Kidney Disease registry, and can be followed at appropriate intervals for ongoing, coordinated care.  That patient did not fall between the cracks!

“We don’t know what we don’t know!”

I like to remind providers that, “we don’t know what we don’t know!”  What I mean by this is that doctors (and all providers, for that matter) are not good at knowing which patients should have come in for care – but have not been seen.

Providers are also not good at knowing every patient with an abnormal lab trend who might enter in to a category requiring care, such as my example of deteriorating kidney function.  On the other hand, computers are excellent at doing this if given the correct algorithm.

This leads me to my next point, which is that while high-functioning Disease Management (DM) programs rely on high-caliber staff, they are also entirely dependent on good data and excellent information technology.  The absence of good data can result in over or under identifying the correct patients for the DM registry.  Inadequate IT can also result in incorrect identification of patients.

Staffing a disease management program

The “effector arm” for a successful DM program requires well trained and dedicated staff.  The leadership team usually involves a Medical Director or Chief Medical Officer, usually assisted by a data analyst, an administrator, and a number of nurse care managers who oversee the outreach to patients.  The number of staff will depend on the magnitude of the DM programs and total number of patients managed.

The initial development of a DM program will usually benefit from the advice of a specialist –  a nephrologist (kidney specialist) in the example above of a Chronic Kidney Disease program.  Once the DM program is up and running, some intermittent evaluation and oversight by the specialist is useful to make certain treatment guidelines and other clinical decision making is on track.

Supporting disease management staff with IT

IT is again important, not only for identifying patients who should be entered into a DM program, but also for the tracking of results.  IT is used to keep track of the number of patients in the DM registry, their overall healthcare utilization and spending, and ultimately their clinical outcomes as compared with standard benchmarks.

Disease management as part of a larger value based care strategy

DM programs improve the quality of care of a population at a low cost.  These programs work best when spread over a large population – more than 50,000 patients.  They also focus on chronic illnesses that mostly affect the elderly population – Chronic Kidney Disease, Heart Failure, Chronic Obstructive Pulmonary Disease, End of Life/Palliative Care, Diabetes and Behavioral Health.  The last two categories – Diabetes and Behavioral Health – are also prevalent in the younger commercial and Medicaid populations.  DM programs can also be effective for Asthma which has more of a pediatric population.

The economic business case supporting the development and use of DM programs works best in a fee-for-value or global payment system, where the incentives for the providers line up to provide better quality longitudinal care with overall decreased medical utilization and spending.  In future blogs, I will touch on some of the unique issues in several specific DM categories.

Rich Parker, MD is the chief medical officer at Arcadia Healthcare Solutions.

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.