Health plans begin to address chronic care management.

I t’s no less true for being obvious: Educating and managing patients with chronic conditions is an effective way to stabilize overall health care costs. Now it appears that health plans are beginning to grasp the obvious. “If you can’t manage comorbidities for those patients, there’s no hope of holding down costs,” says Michael Mustille, MD, associate executive director of the Permanente Federation, which coordinates the quality improvement efforts of the Permanente Medical Groups and the 8,500 physicians associated with Kaiser Permanente. Kaiser has had programs in place for several years managing chronically ill patients. But Kaiser’s attempt to manage chronically ill patients has been the exception; most plans are only lately beginning to address chronic care management. Virtually all health plans’ benefit structures are calculated to treat people episodically, for acute care rather than chronic care. Patients with chronic conditions generally are not taught how to care for their own illnesses, says Thomas Bodenheimer, MD, a clinical professor in the Department of Family and Community Medicine at the University of California San Francisco Medical School. Bodenheimer has written extensively about treating chronically ill patients. “Doctor visits are short and without planning to make sure that chronic needs are addressed. Caring for chronic illness usually features uninformed and passive patients interacting with an unprepared practice team,” he says. That model of care is expensive. Studies show that 80 percent of overall health care costs results from treating about 20 percent of the population. “The 80–20 rule is a well established guiding principle,”says Chris Wise, PhD, administrative director of the Medical Management Center at the University of Michigan Health System.“Finding those 20 percent and getting them the care they need means managed care needs to go beyond utilization review and recognize the need for chronic care management.” The center offers disease management programs for UMHS patients with diabetes, asthma, depression, heart failure, and coronary artery disease. Mustille and colleagues at Kaiser’s Care Management Institute (CMI) in Oakland advocate aggressive treatment for people with chronic conditions. Their programs go beyond disease management, says Mustille, in that they are highly integrated into primary care protocols. In 1999, Kaiser Permanente launched care management programs through CMI that target diabetes, coronary artery disease, hyperlipidemia, asthma, and congestive heart failure. The plan has since added depression. Kaiser has invested millions in the CMI programs, hoping to improve outcomes and thereby create savings through fewer hospitalizations and emergency department visits. It has been successful, says Mustille, and recently he has presented CMI’s work at several health plan symposiums.“More managed care plans are lookHealth Plans Begin To Address Chronic Care Management As with so much else in health care, observing protocols, analyzing data, and rethinking benefit designs are important.