Integration of Case and Disease Management
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Dis Manage Health Outcomes 2002; 10 (5): 277-289 1173-8790/02/0005-0277/$25.00/0 © Adis International Limited. All rights reserved.
Integration of Case and Disease Management Why and How? Margaret A. Radzwill Healthcare Management Consulting Services, Houston, Texas, USA
Contents Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Why Are Case/Disease Management (CDM) Programs Necessary? . . . . . . . . . . 1.1 Chronic Disease States – Their Impact on Cost and Outcomes . . . . . . . . . . . 1.2 Morbidity and Mortality Associated with Chronic Disease States . . . . . . . . . . 2. Defining Case (CM) and Disease (DM) Management . . . . . . . . . . . . . . . . . . . 2.1 Traditional Case Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.1 Case Management Components . . . . . . . . . . . . . . . . . . . . . . . . 2.2 Defining Disease Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.1 Disease Management Program Components . . . . . . . . . . . . . . . . . . 2.3 Differences in CM and DM Programs . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Defining an Integrated CDM Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1 Medical Management Transition to CDM . . . . . . . . . . . . . . . . . . . . . . . 3.2 Incorporating Various Program Aspects . . . . . . . . . . . . . . . . . . . . . . . . 3.3 Organization and Infrastructure to Support a CDM Model . . . . . . . . . . . . . 4. Demonstrated Cost Savings Observed with CM, DM and CDM Initiatives . . . . . . . . 4.1 Cost-Saving Potential of DM Programs (Employer-Sponsored Program) . . . . . . 4.2 Cost-Saving Potential of CM Programs (Health System–Sponsored Program) . . . 4.3 Cost-Saving Potential Of CDM Programs (Employer– and Health Maintenance Organization Sponsored Program) . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Barriers that Can Hamper the Success of CDM Programs . . . . . . . . . . . . . . . . . 5.1 Medical Management Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.1 Utilization Review Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.2 Case Management Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.3 Restricted Health Plan Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.4 Restricted Drug Formularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Other Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Achieving an Integrated CDM Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Outcomes Management Initiatives in a CDM Model . . . . . . . . . . . . . . . . . . . 7.1 Defining Health Outcomes and Their Scope . . . . . . . . . . . . . . . . . . . . . . 7.2 Other Health Outcome Classifications . . . . . . . . . . . . . . . . . . . . . . . . . 7.3 Physician and Health Insurer’s Role in Outcomes Management . . . . . . . . . . 7.4 Technology Tools to Support Outcomes Management . . . . . . . .
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