Disease Management Programs: Barriers and Benefits
Published Online: April 16, 2013
Racheli Magnezi, MBA, PhD; Galit Kaufman, RN, MA; Arnona Ziv, MBA; Ofra Kalter-Leibovici, MD; and Haim Reuveni, MD
Healthcare markets are characterized by increasing costs, as well as by gaps in quality, safety, equity, and access. These are the result of market failure, observed when services are funded without evidence of cost-effectiveness. Chronic diseases are a major burden on the healthcare system. Disease management programs (DMPs) are the preferred means for helping chronically ill patients comply with their care. A DMP is defined by the World Health Organization as “ongoing management of conditions over a period of years or decades, by providing and improving the necessary resources and support to enable patients’ self management skills.”1,2
Disease management programs aim to reduce waste, increase the efficiency of healthcare delivery, and reallocate resources to improve value.3 Porter4 noted that achieving high value for patients must become the overarching goal of healthcare delivery, with value defined as the health outcomes achieved per dollar spent. If value improves, patients, payers, providers, and suppliers all can benefit, while the economic sustainability of the healthcare system is strengthened.4
Disease management programs can lead to improvements in health. Interventions such as patient and provider education, feedback, and reminders have been successful in increasing provider adherence to guidelines, enhancing patient satisfaction,5-7 reducing morbidity8 and mortality,9 and improving patient disease control and health status10 in conditions such as diabetes11 and depression.12 Disease management programs have also been effective for patients with asthma, arthritis, and coronary artery disease.13
The economic effectiveness of DMPs is not clear.14 Some studies have found a net cost savings for DMPs and a return on investment of $1.26 per $1.00 spent on disease management services for patients with asthma, congestive heart failure, and diabetes.15 Other studies showed that DMPs are associated with increased costs for diabetes and coronary artery disease,16 but not for asthma. Short-term costs might increase, but financial relief appears over the long term from a decrease in the incidence of diabetes-related complications and fewer hospital visits.17,18
Financial savings are realized after about 3 years and depend on the type of intervention program.19,20 Some chronic obstructive pulmonary disease (COPD) programs have led to fewer hospitalizations and emergency department (ED) visits.21 However, a systematic review of multiple interventions in asthma and COPD revealed no significant improvements in the number of ED visits or in pulmonary function.22 Wennberg and colleagues23 demonstrated that by using a telephone-care management program, medical costs were reduced by almost 10% after 12 months. Other studies demonstrated that only DMPs that include financial incentives for physicians24-26 and/or patients18 are efficient and lead to improved health outcomes and compliance.
Benefits from implementing DMPs largely depend on the structure of the specific healthcare system, including financial arrangements, staffing, and level of service. Although economic and organizational efficiency in a given system might improve, this does not necessarily imply that the improved efficiency will be replicated in other systems.
Israel’s national health insurance law provides all citizens with basic healthcare coverage. Healthcare is provided by 4 health funds, which are structured as health maintenance organizations (HMOs). The HMOs are faced with growing costsof providing health services and increasing numbers of chronically ill patients. They recently implemented DMPs for a number of chronic illnesses, including congestive heart failure, COPD, and depression. In the initial stages of the programs, administrative difficulties were revealed, along with barriers to conducting these programs in primary care clinics. The focus of this study was to investigate the origins of these obstacles. Therefore, we interviewed senior healthcare managers and policy makers in Israel to assess their attitudes toward barriers to implementing DMPs within the national healthcare system.
A 21-item questionnaire was composed by the investigators, based on their experience in planning, implementing, and evaluating DMPs. Following a pretest of the questionnaire for clarity, in-depth interviews were conducted with 24 nurses and physicians in the health system who were familiar with implementing DMPs. The questionnaire was revised based on their comments.
The questionnaire included 3 sections: (1) demographic and occupational characteristics; (2) attitudes about the potential benefits of DMPs to the healthcare system, to community medical staff, and to patients with a chronic illness, and opinions about which professionals are most suited to managing a DMP; and (3) attitudes regarding barriers that might prevent healthcare system policy makers and community medical staff from implementing DMPs. Responseswere ranked on a Likert scale from 1 (strongly agree) to 4 (strongly disagree). After each section, the respondent was asked to rank the answers marked “strongly agree” from 1 to 3, to determine a priority ranking for each series of questions (barriers, benefits, and professional management).
This cross-sectional survey was conducted in Israel from March to September 2010. The study population consisted of 105 senior healthcare administrators and included academic policy makers as well as top managers from the Ministry of Health and all 4 healthcare funds. Respondents’ professional backgrounds included physicians, nurses, pharmacists, and social workers. The fields of mental health and dentistry were not included. All respondents had held their current position for at least 2 years. Of these, 87 (83%) respondents agreed to schedule time to complete the survey in the presence of one of the investigators. This was done to improve the response rate. The interviews were conducted by investigators who were familiar with DMPs in Israel. They did not provide any assistance in completing the questionnaires.
The data were analyzed using SAS version 9.2 (SAS Institute, Inc, Cary, North Carolina). For each statement in each question, 2 variables were built: 1 for the Likert scale responses and 1 for ranking the statements that were marked “strongly agree.” Respondents were categorized into 3 groups: physicians, nurses, and others (paraprofessional and administrative personnel). For categorical variables, the Pearson x2 test or Fisher exact test, as appropriate, was used to compare the distributions of the 3 groups. The continuity-corrected x2 test was used for binary variables.
A total of 87 senior executive managers, representing about 83% of all senior administrators of the national health care system, participated in the study. Most of the respondents (79.3%) held managerial positions in the HMOs, and 18 (20.7%) had positions in the Ministry of Health.
Table 1 presents the background characteristics of the study participants; 65.5% were male, 47% were physicians, 22 (25.3%) were nurses, and the remainder were paraprofessional and administrative professionals. Among the respondents, 63 (72.4%) had experience planning, implementing, or evaluating a DMP.
Attitudes Toward Disease Management Programs.
Almost all respondents (96.6%) replied that DMPs are important for the healthcare system and that healthcare organizations should include them in their 5-year strategic plans.
Managing a Disease Management Program. Overall, 79 (90.8%) respondents indicated that a DMP should be implemented by a multidisciplinary team. Thirty-three (37.9%) stated that the program should be headed by a physician, 28 (32.2%) preferred a nurse, and only 6 (6.9%) indicated that a doctor and nurse should head the program jointly. A significant link was found between the respondents’ professions and their views on who should head the DMP, with 58.5% of physicians saying it should be a physician, and 68.2% of the nurses stating that a nurse should head the program (P <.001).
Implementing Disease Management Programs. A total of 82 (94.3%) participants responded that implementing DMPs was a very important component of the healthcare system. The majority (n = 44 [50.6%]) said that it was the responsibility of the HMOs to implement DMPs. The remaining responses were split between allocating the responsibility to the Ministry of Health (n = 21 [24.1%]) or to the Ministry of Health and the 4 national HMOs as a joint venture (n = 22 [25.3%]). In the latter case, the ministry would assume responsibility for administrative management and allocating resources to the programs, and the HMOs would implement and promote them.
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