Disease Management, Coursework Example

Introduction

Regulatory Background (the regulation for patient safety, treatment options and recommendations of organizations)

According to Pilnick et al. (2001, p. 755), the main aim of the recent health care policy reforms across the United States ans most Europe was to control costs and implement quality assurance into disease management. Patient safety has been in the focus of the new policies, and decision-makers also attempted to ensure that preventive methods are fully outlined in disease management policies. Managed care disease management programs in the past few years have been changing, due to the different approaches required by policies, according to Draper et al. (2002, p. 11.) Further, risks are eliminated by new managed care disease prevention and management practices, while safeguarding profitability. (p. 17.)

Issues and Challenges

Environmental challenges of managed care

Managed care organizational environments differ from traditional health care providers’, according to Pilnick et al. (2001, p. 756) Managed care, according to the authors (p. 756) is “generic term for a variety of attempts to alter or restrict the treatment behaviours of health care professionals in order to produce both clinically effective and cost-effective outcomes”. While the traditional approach towards health care is based on a single fee charged per medication or treatment, managed care is a more complex system. Managed care organizations in the United States can have been focusing on a system that covers prevention, diagnosis, intervention and after-care services, such as rehabilitation.

Cost effective managed care approach vs. effectiveness

Pilnick et al. (2001, p. 756) states that the ultimate goal of disease management programs in managed care should be to “produce optimal health care outcomes” while enhancing the quality of care and controlling costs. This also implies that while the cost of managed care services is based on staff expenditures, medication and other resource use, financing the plan and implementing quality assurance guidelines requires a coordinated approach. (Pilnick et al. 2001, p. 756)

Sekhri (2000, p. 836) notes the most prevalent complaints regarding managed care costs. According to the author, (2000, p. 835) some researchers state that the introduction of managed care services in the U.S. health care system did not result in significant cost saving; indeed, a survey among consumers states that 60 percent believe that it resulted in higher costs. The author also states that there is indeed a relationship between the increased use of managed care programs and the increase of health care costs. (2000, p. 835)

Focus on prevention

Sekhri (2000, p. 833) states that managed care should focus on emphasizing prevention and providing health education, as it is a more cost-effective option than treatment. Draper et al. (2000, p. 20) also call for a wider implementation of preventive care, wellness and health education programs. It is widely known that prevention is a more cost-effective approach towards health care than treatment, therefore, in order to utilize this feature of disease management, there is a need for creating a framework that determines the steps towards identifying needs, patient assessment and follow-up procedures.

Importance of Disease Management

According to Draper et al. (2002, p. 19), eight out of ten insured adults in the United States are currently enrolled in one of the managed care programs, however, this does not imply better health outcomes, unless the policies and quality measures are reviewed and adjusted to patients’ needs on a regular basis. Increased premium, according to Draper et al. (2002, p. 20) does not result in a higher quality of care.

Performance Outcomes

Sekhri (2000, p. 840) suggests that quality report cards would be used within managed care. The simple measures would indicate the effectiveness of the disease prevention and management program, as well as highlighting the increase or decrease of associated costs. The use of report cards, according to the author (p. 839) would reduce variations in the quality of service, support change management and help the leadership develop adequate internal guidelines, policies and practices that result in the best possible patient outcome.

III. The Managed Care Environment

Specifics of Managed Care Environment

Clinical guidelines

Managed care often restricts physicians in carrying out diagnostic tests and perform certain procedures. (American Medical Association, 1995, p. 3) Guidelines require managed care practitioners to request approval for ordering tests. (American Medical Association, 1995, p. 2) and this lengthy process reduces the effectiveness of care, while increasing the cost of the program. Physicians are also often provided incentives on top of their salary for reducing the number of diagnostic tests requested, therefore, decisions affecting patients are often made on financial incentives.

Ethical considerations

Ethical considerations of managed care include balancing the interest of different patients, decisions made based on needs, status, treatments available and associated risks. (American Medical Association, 1995, p. 2) Further, patient autonomy and responsibilities need to be highlighted and clearly communicated within managed care environment. According to the American Medical Association Report, (1995, p. 9), the incentives to limit care should be communicated with patients, as well as the minimum standards of care. Further, the authors indicate that incentives provided for managed care disease management practitioners should be based on quality of care and patient outcome targets, rather than cost-saving initiatives.

Challenges of Managed Care Environment

According to Draper et al. (2002, p. 21), the main challenge of managed care strategies today is that the market is shifting towards a less restrictive range of products, and this results in organizations losing their ability to control and manage the costs.

Program implementation

Sekhri (2000, p. 834) describes the ideal, well-developed integrated managed care system through a flow-chart. The author states that the complexity of transaction costs, intervention, immunization make the implementation extremely challenging. The author recommends that within managed care disease management programs, managers would replace uncontrolled fragmentation with managed complexity. (2000, p. 833) Pilnick et al. (2001, p. 762) describes the U.S disease management and managed care system as one that has a strong tradition but limited regulation, policy authority. This also indicates that there is an increased need for implementing internal frameworks, regulations on an organizational level in order to preserve cost-effectiveness and maximizing patient benefits.

Performance measures and targets

Performance measures within managed care need to be identified individually for all diseases. As mentioned above, quoting Pilnick et al. (2001, p. 756) the system is complex, therefore, there is a need for simplifying patient outcome measures and targets. Patient satisfaction surveys, treatment times, costs, risks and health outcomes need to be measured in order to re-evaluate the effectiveness and cost-effective approaches of managed care disease management programs.

Implications

Financial Implications

The sources of funding are complicated within the U.S. System: while there are whole system capitation payments alongside with individual specialist’, providers’ and physicians’ salaries. The existence of incentive payment on top of health care provider staff’s salary makes the management of costs almost uncontrollable. That implies that there is a need for the simplification of funding, cost and quality management in the policies of the United States, after carefully reviewing the funding and expenditure system of managed care facilities, as well as disease management programs within.

Policy Implications

While the economic strength of the health care market and patients’ ability to pay for health care plans is declining (Draper et al. 2002), the system is currently unable to absorb health care cost increases. This also calls for a policy review that maximizes the benefits of less restrictive care and re-evaluates the effectiveness, cost and adaptability of available disease management health care solutions, ensuring that they serve the main purpose of managed care: providing the best possible patient outcomes at the lowest possible costs.

Conclusion

Sekhri (2000, p. 836) clearly states that “the evidence shows that managed care has had an impact on stemming the escalating growth of US health care costs”. This indicates that managed care programs are designed to be expensive and costly. However, it is not the case. It has been reviewed that the complexity of the care, the liberal approach towards treatments and medication make controlling costs challenging. Instead of returning to the traditional model of health care, Pilnick et al. (2001, p. 756), researchers and health care professionals should be looking at new ways of controlling costs, while maintaining the quality of care, providing the best possible disease management outcomes for patients. This calls for a model for implementation, which is currently not available, as well as measurable outcome targets to be introduced into managed care.

References

American Medical Association. (1995) Ethical issues in managed care. CEJA Report 13 – A-94 1.11

 Draper, D., Hurley, R., Lesser, C., Strunk, B. (2002) The changing face of managed care. Health Affairs, 21, no.1 (2002):11-23

Sekhri, N. (2000) Managed care: the US experience. Bulletin of the World Health Organization, 2000, 7

Pilnick, A., Dingwall, R., Starkey, K. (2001) Disease management: definitions, difficulties and future directions. Policy and Practice. Bulletin of the World Health Organization, 2001, 79(8)