Perceived barriers and benefits to implementing disease management programs among Israeli healthcare leaders could assist other countries faced with increasing numbers of chronically ill patients.
The healthcare system in Israel faces difficulties similar to those of most industrialized countries, including limited resources, a growing chronically ill population, and demand for highquality care. Disease management programs (DMPs) for patients with a chronic illness aim to alleviate some of these problems, primarily by improving patient self-management skills and quality of care. This study surveyed the opinions of senior healthcare administrators regarding barriers, benefits, and support for implementing DMPs.
A 21-item questionnaire was self-completed by 87 of 105 (83%) healthcare administrators included in the study. Participants were 65.5% male and 47% physicians, 25.3% nurses, 17.3% administrators, and 10.3% other healthcare professionals.
The main perceived benefit of DMPs among all respondents was improving quality of care. Other benefits noted were better contact with patients (81.6%) and better compliance with treatment (75.9%). Efficient long-term utilization of system resources was perceived as a benefit by only 58.6%. The main perceived barriers to implementing DMPs were lack of budgetary resources (69%) and increased time required versus financial compensation received (63.2%).
The benefits of DMPs were patient oriented; barriers were perceived as financial and limiting professional autonomy. Information regarding long-term benefits (better patient outcomes) that ultimately provide better value for the system versus short-term barriers (increased costs and expenditures of time without compensation) might encourage the implementation of DMPs in countries faced with a growing population of patients with at least 1 chronic illness.
Am J Manag Care. 2013;19(4):e140-e147A survey among healthcare executives regarding implementing disease management programs (DMPs) found that perceived benefits were patient oriented (improving quality of care, better contact with patients, and better compliance with treatment). Barriers were perceived as increased costs, expenditures of time without compensation, and limiting professional autonomy.
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.
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.
Prioritizing Clinical Domains for Disease Management Programs. Diabetes and congestive heart failure were noted by 94.3% and 90.8% of the senior managers, respectively, as conditions that could benefit from a DMP. Only 40.2% agreed that a DMP might be helpful for depression and anxiety. There were no differences between the opinions of senior physicians, nurses, paraprofessionals, and administrative personnel about the priority of implementing these programs. However, more nurses than physicians thought that DMPs would be most effective in improving outcomes in illnesses such as hypertension (81.8% vs 56.1%, respectively; P = .05), asthma (72.7% vs 46.3%, respectively; P = .02), and COPD (90.9% vs 60% respectively, P = .03).
Benefits to the Healthcare System From Implementing Disease Management Programs. Figure 1 shows the perceived benefits of implementing a DMP. Improving quality of care was ranked as most the beneficial aspect by all respondents (89.6%). As seen in , nurses perceived more benefits from implementing DMP programs than physicians and other professional managers, including improving caregiver satisfaction, improving knowledge and professionalism, better contact with patients, and improving the patient’s quality of life.
Physicians and other managers expressed significantly stronger agreement than nurses with the indicator, “Better access to health services and preventing errors.” On the other hand, both physicians and nurses agreed that the DMPs would contribute to efficient, long-term utilization of system resources.
There were no significant differences among the study participants regarding the remaining potential benefits. Improved tools for treatment and better compliance with treatment were viewed as equally beneficial by all respondents.
Among the questionnaire responses rated “strongly agree,” the top 3 ranked benefits for the healthcare system were improving the quality of care, better contact with patients, and better compliance with treatment. These are denoted by the red bars in Figure 1.
Barriers to Implementing Disease Management Programs. The top 3 perceived barriers to implementing DMPs were lack of budgetary resources (69%), increased investment of time versus reward received (63.2%), and lack of physical resources, training, and manpower (63%) (). The barriers marked “strongly agree” were prioritized as lack of resources, increased investment of time versus reward, and fear of losing autonomy, professional status, and authority. These are denoted by the red bars in Figure 2. As seen in , nurses indicated significantly more barriers than physicians, such as management’s lack of awareness of the importance of DMPs, lack of organizational commitment, and lack of budgetary resources.
The need to invest more time in patient education and increased burden on community medical staff were cited equally by all respondents. Physicians and nurses tended to place more importance on the need for compensation and incentives. A higher percentage of nurses than physicians and other managers noted low caregiver motivation due to lack of organizational support and lack of faith in the success of DMPs, but these differences were not statistically significant.
In 2011, the World Health Organization placed DMPs at the top of its global and national agendas, and presented a comprehensive strategy and goals for implementing such programs. 2 In this study, most participants agreed that healthcare organizations should include DMPs in their 5-year strategic plans.
The profile of patients with chronic illnesses (in terms of prevalence rates and needs) in Israel is similar to that of other Organisation for Economic Co-operation and Development (OECD) countries, the European Union, the United States27-36 and other countries such as New Zealand.37 The health system in Israel is similar in many ways to those in countries with national health insurance, including England, Canada, and Germany. However, it differs greatly from countries where the healthcare system is driven by economic factors, such as the United States. In spite of this, we believe that some of the perceived barriers and benefits found in this study—including quality issues, financial and professional concerns, and fear of organizational changes—are common to all healthcare systems.
Similar to other studies, our results show that DMPs are perceived as beneficial to patients.5-8,10 Disease management programs can lead to improved communication between healthcare providers and patients, and help patients learn to improve their self-care skills.1,2 These programs have led to better compliance with treatment regimens5-7 and could promote efficient long-term utilization of system resources. Although DMPs have numerous potential advantages, there is no global consensus that DMPs actually increase the efficiency of healthcare delivery or add value to the system.38
We found that the main barriers to implementing DMPs were lack of funding, the need to invest more time with the patient, and lack of organizational support for caregivers. As seen, financial incentives alone will not overcome the barriers to implementing DMPs. Rather, it is important to provide education and information about the experiences of other health systems to help staff believe in the success of DMPs.
In almost every healthcare system worldwide, DMPs are implemented and administered successfully by nurses.39-41 Nurses recognize the potential for professional growth and knowledge through DMPs, as well as the possibility for meaningful improvements in patient care. However, nurse administrators also recognize the structure of the healthcare organization hierarchy and know that it is not easy to successfully implement these programs because of existing barriers. This dichotomy explains the propensity of the nurse administrators to identify both more barriers and more benefits to DMPs than the other professionals queried.
Although nurse managers identified fear of loss of autonomy as a barrier, the opposite usually occurs. Nurses tend to gain increased status and autonomy related to their responsibilities regarding implementation of DMPs. On the other hand, physicians appeared to feel secure in their autonomy and did not anticipate a loss of status.42,43
Even though some of the differences in responses between the professions were not statistically significant because of the small numbers in each group, the physicians and nurses queried seemed to be more aware of the potential benefits of DMPs than the paraprofessionals and administrative managers (Table 2). That might have been because they were more involved in the daily aspects of direct patient care.
Implementing DMPs requires organizational change.As seen in our results, staff might be afraid of change and will need reassurance that DMPs will not compromise their professional status or prestige. The key for success is theinclusion and collaboration of all parties in the implementation process, enabling them to overcome perceived barriers, including uncertainties and reallocation of resources. The medical team needs information, training, practice, support, empowerment, and reinforcement to increase the skills required by DMPs and to reduce burnout.31-34 Introducing incentives for implementing DMPs might increase the use of these programs.28 Financial incentives for healthcare staff—in the form of rewards for improved medical results,38 payment for performance,44 home visits, and unreimbursed encounters with patients such as phone calls and e-mails—have been found helpful. Incentives for healthcare providers (HMOs) are an additional way to encourage implementantion of DMPs. Such an action plan was successfully initiated in Germany.45 Another possible incentive would be for the government to allocate additional funds to the HMOs for program implementation; later, when DMPs demonstrate a financial advantage, the HMO budgets will bear the financial responsibility for them.
Healthcare organizations consider cost-effectiveness when allocating resources. The cost-benefit ratio of DMPs varies greatly across healthcare systems, in particular because of their complexity. The vast array of variables involved in DMPs makes it very difficult to assess both their clinical effectiveness and their cost-effectiveness.46,47 Some studies that evaluated DMPs did not find short-term cost savings and revealed unclear long-term results, which are barriers to implementation.21,25
Our results indicate that senior managers recognize the importance of DMPs and their potential benefits. However, because there is not yet strong evidence of their effectiveness, financing their implementation competes with other more urgent needs. It is possible that the results of 3 ongoing clinical trials examining the effectiveness of DMPs among patients with heart failure and chronic lung disease will be an incentive for health policy makers to adopt or reject such programs in the health system in Israel.
This study has a few limitations. The results are based on a survey of senior-level healthcare administrators and policy makers in Israel. However, because the Israeli system is similar to the systems in most OECD countries, these results might be applicable to countries that are also facing increasing numbers of patients with at least 1 chronic illness. Obtaining the opinions of doctors and nurses in the field who would have to implement DMPs within their scope of practice would likely add valuable information about this subject.
The findings reported here add information regarding perceived benefits and barriers to implementing DMPs and suggests that DMPs are important to healthcare systems. The controversies regarding DMPs should challenge investigators to provide more information to policy makers in order to eliminate barriers and to enable the provision of better care to patients with a chronic illness.
As suggested by the World Health Organization, DMPs add value to healthcare systems. Internal and external barriers to implementing DMPs are common to many countries. Disease management programs can enable organizations to provide better healthcare; therefore, DMPs can be regarded as an important investment in the future of a healthcare organization. The controversies regarding the value of DMPs should challenge investigators to provide more evidence of their benefits to healthcare providers on all levels.The authors thank the Israel National Institute for Health Policy Research for providing funding for this study, as well as Faye Schreiber, MS, for editorial assistance.
Author Affiliations: From Public Health and Health Systems Management Program, Department of Management (RM), Bar Ilan University, Ramat Gan, Israel; The Gertner Institute for Epidemiology and Health Policy Research (RM, GK, AZ, OK-L), Tel Hashomer, Tel Aviv, Israel; Ben Gurion University of the Negev (HR), Beer Sheva, Israel.
Funding Source: This study was funded by the Israel National Institute for Health Policy Research (grant 32/2009/r).
Author Disclosures: The authors (RM, GK, AZ, OK-L, HR) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (RM, GK);acquisition of data (RM, GK); analysis and interpretation of data (RM, AZ); drafting of the manuscript (RM); critical revision of the manuscript for important intellectual content (RM, GK, AZ,OK-L, HR); statistical analysis (RM, AZ, OKL, HR); provision of study materials (RM, GK, AZ, OK-L, HR); obtaining funding (RM); administrative, technical, or logistic support (RM, GK); and supervision (RM,GK).
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