# Presentation: 946971

## Stretching Scarce Resources: State Strategies to Design Effective, Affordable Benefit Packages

**Autumn Dawn Galbreath, M.D.**
**Director**
**University of Texas Disease Management Center**

**Notes:**
Autumn Dawn Galbreath’s slides for the presentation “Stretching Scarce Resources: State Strategies to Design Effective, Affordable Benefit Packages.” 

Autumn Dawn Galbreath is the Director of the University of Texas Disease Management Center. 

## Introduction to Disease Management (DM)

- Systematic, population-based approach
- Identifies people at risk
- Intervenes
- Measures outcomes

**Notes:**
The most concise definition of disease management is managing a disease - the ongoing management of one particular disease in a given patient. 

Disease management is a systematic approach that focuses not just on an individual patient but also on a population of patients who have that disease. It identifies the people who have the disease, then intervenes to care for the disease in an ongoing fashion, and then it measures outcomes. An integral part or one of the basic principles of disease management is that it is constantly looking at its own effectiveness. 

## Important Characteristics

- Best practices throughout the entire continuum of care
- Clinical guidelines
- Reduced cost
- Improvement of measurable outcomes in the quality of care

**Notes:**
Disease management employs best practices of medical care so that it is always using published clinical guidelines or the consensus of expert opinion in a region or in a locality so that it can reduce costs and improve quality.

## “Management Soup”

- Case Management
- High-Cost Case Management
- Disease Management
- Population Management
- Managed Care

**Notes:**
There are so many terms that all have the word “management” in them and they are frequently used and misused or substituted inappropriately for each other. Case management is a generic term for giving attention to an individual patient for whatever reason a patient needs a little attention from the healthcare system. This is typically an allied health professional, a nurse, or another provider working individually with a patient in a long-term situation. 

High-cost case management is a subset of case management. It is the management of individual patients who are high utilizers of the system. They may have multiple diseases and multiple reasons for being high utilizers so they have a manager or case manager who works with them to try to put all those pieces together and manage the whole picture of their healthcare. 

Disease management is the management of a population with a given disease. A person might have congestive heart failure and diabetes, emphysema and several other diagnoses, but their disease management program would focus only on their congestive heart failure or only on their diabetes. Disease management is distinct in that it focuses on a specific disease or a specific diagnosis within the patient population.

## Does It Work?

- The “literature is now replete with titles in DM, quality improvement, and clinical practice improvement, but...there is not much evidence that {these}...improve efficiency in the care process for the disease.”9
- 9 – Curtiss F. Lessons learned from projects in disease management in ambulatory care. Am J Health-Syst Pharm 1997;54:2217-29.

**Notes:**
The “literature is now replete with titles in DM, quality improvement, and clinical practice improvement, but...there is not much evidence that {these}...improve efficiency in the care process for the disease.” 

## Summary of the Literature

- 24 trials previously published, only 8 of which are randomized and controlled
- CHF: 8 trials
- Diabetes: 3 trials
- Asthma: 1 trial
- Coronary artery disease: 1 trial
- General primary care/postdischarge care: 5 trials

**Notes:**
The existing disease management literature has flaws which make it difficult to answer many questions about disease management. 

## Remaining Questions

- Is DM truly cost-effective in a heterogeneous patient population with a forthcoming and straightforward analysis of the economic data?
- Does DM improve clinical outcomes?
- Does DM improve subjective outcomes such as quality of life and patient satisfaction?
- Does DM improve provider satisfaction with the care they are able to provide?
- Is DM better administered in a face-to-face clinic setting or telephonically?

**Notes:**
A thorough review of the disease management (DM) literature leaves many unanswered questions about the effectiveness of such programs. It is unknown whether DM is truly cost-effective, whether it improves clinical outcomes, if it improves quality of life, and the best way to administer a disease management program is still undetermined. 

## South Texas CHF Demonstration Project

- Target enrollment: 1200 patients
- Target population: Veterans,
- 	Military, Medicare, Medicaid,
- 	and indigent patients
- Time of Enrollment: 18 months

**Notes:**
The South Texas Congestive Heart Failure Demonstration Project at the University of Texas Disease Management Center is a large-scale, randomized clinical trial involving publicly insured patients with congestive heart failure. The aim of the trial is to methodically answer some of the unanswered questions about disease management so that States and academic health centers will have more information from a scientific standpoint when they make decisions based on implementation of disease management programs.

## Disease Selection

- High volume
- High cost
- Variation in management
- Propensity for acute decompensation

**Notes:**
An optimal disease for a disease management program has a high volume of patients and a significant impact on the economics of a healthcare system. It also needs to be a disease that is routinely managed in different ways by different providers in order to figure out the best method of managing the disease. 

## Barriers to DM

- Acute care model of the current health care system
- Lack of integrated information systems
- Lack of provider support
- Limited resources
- Danger of fragmentation of care

**Notes:**
One of the biggest barriers to implementing a disease management program is our healthcare system itself. The United States healthcare system is structured as an acute model of care where the most acute patients get the most attention and in between acute episodes they can slip through the cracks. That system is what works against managing chronic diseases. 

Another huge barrier is information systems. Every doctor’s office, every hospital, and every public health clinic has its own information system, which makes it difficult to work together as a multi-disciplinary team within a healthcare setting because our information systems don’t work together well. 

Other barriers are lack of physician support and the danger of fragmentation of care. 

## Lessons Learned

- Provider Buy-In
- Start-Up Costs and Savings Realization
- “Don’t promise what you can’t deliver”

**Notes:**
Important lessons learned from implementing the South Texas CHF Disease Management Program include the necessities of provider support, the realization that start-up costs may have to be high in order to realize savings down the line, and programs should not promise what they can’t deliver to providers, patients, legislatures, or the community. 

## For additional information, contact:

- Autumn Dawn Galbreath, MD
- Director
- University of Texas Disease Management Center
- 4243 Piedras Drive East #240
- San Antonio, Texas  78228
- (210)567-9700 (office)
- (210)756-8184 (pager)
- galbreath@uthscsa.edu

**Notes:**
For additional information contact: 
	Autumn Dawn Galbreath, MD
	Director
	University of Texas Disease Management Center
	4243 Piedras Drive East #240
	San Antonio, Texas  78228
	(210)567-9700 (office)
	(210)756-8184 (pager)
	galbreath@uthscsa.edu

## Disease Management in Uninsured Populations

- Florida Medicaid Disease Management Initiative
- Virginia Health Outcomes Partnership
*Easy Breathing* (Hartford, CN)
- National Jewish Asthma Disease Management Pilots

**Notes:**
There are definitely Medicaid programs that are implementing disease management and there are definitely success stories - it is just that they are not far enough along yet to have a lot of data to study. 
The State of Florida began a disease management program about four years ago, and now manages six or eight diseases. 
The Virginia Health Outcomes Partnership also has disease management-type programs for their asthmatic patients, which focuses mostly on provider education. 
The Easy Breathing Program in Hartford, Connecticut is an example of a successful asthma management program, and there are several pilots using the National Jewish and Medical Research Center Asthma Protocol in Medicaid populations. 
Although it is too early for definitive data from these studies, they provide a lot of positive anecdotal evidence for disease management.