Emerging Trends - From Component
To Disease Management

Larry Tremonti, M.D.
Larry Tremonti, M.D. is Vice President, Care and Delivery Systems
Management, for Blue Cross and Blue Shield of Florida, Inc.

Within the health care industry the focus on managing specific diseases has been smoldering for years, as medical practice has become increasingly specialized. The earliest change was represented by specialization into physiologic disciplines, such as cardiology and pulmonology. As our scientific knowledge and technological capabilities grew, pressure mounted to subspecialize within these areas. Additional avenues were created by focusing on specific modalities (diagnostic or therapeutic) or bodily organs.

The natural evolution, therefore, has been for physicians and other providers to specialize further by disease states or medical conditions. However, in the process of superspecial-izing by disease, the focus on the patient was lost. Counterpressure soon built-up to balance this fragmentary, disease-focused approach with a more comprehensive, integrated, and systematic patient-centered approach. The tension created by these two converging approaches has led to a combined disease-focused and patient-centered approach, such as in oncology, where multidisciplinary provider teams used clinical protocols to manage patients diagnosed with a specific type of cancer. By measuring the clinical outcomes of these patients, oncology teams were able to update their protocols to provide optimal care or "best practices."

On the horizon and currently under development is a new paradigm of health care management that has been coined "Disease Management". Defined as a proactive, coordinated approach to medical care delivery, the disease management movement has taken the industry by storm.

There are three primary elements of disease management:

Many managed care players have high expectations for disease management. They believe that focusing on patients grouped by their common medical conditions will control cost, improve clinical outcomes, and create system value.

When health care professionals first hear of Disease Management, typical reactions are "How is that different from other healthcare techniques?" or "We already do that." Its unique qualities become clearer when Disease Management is compared with Component Management — the traditional approach to managing health care cost.

In Component Management, the individual healthcare transaction (the doctor's visit or procedure) is viewed as the relevant unit of service and cost. The treatment cycles, various transactions, and component categories are analyzed to establish statistical norms for unit costs and frequency in a population or provider's practice. Incentives and penalties encourage compliance with the norms, thereby reducing some of the extreme practices, such as non-essential operations, excessive tests, and too many pharmaceuticals. The unit cost of each component is then driven as low as possible through aggressive contracting, utilization management, case management, and other cost control techniques. Component Management provided one of the first tools to address the reluctant growth of heath care cost.

The distinction between Disease Management and Component Management is critical from a competitive perspective. Clearly, many health systems can become more efficient using conventional techniques, but they can only progress so far. Building a competitive advantage in the future will require a more fundamental redesign of care than is possible with a component based approach.

In Disease Management, groups of patients with the same disease are the most important units of analysis. This perspective gives disease management several advantages over component management:

  1. Disease management provides a clean sheet, systemic view of health care management that can fundamentally change practitioner's perspectives. It assumes that the overall structure of healthcare is direction.
  2. Disease management approaches cost and use according to clinical need and system-wide economic impact.
  3. Disease managers work closely with physicians to develop more creative and effective solutions with higher level of buy-in.
  4. Disease management emphasizes the optimum employment of resources, ensuring that patients receive the care they need in the most appropriate setting, from the right physician or practitioner. It does so with continual self correction.

Disease Management goes deeper and forces more fundamental rethinking than Component Management with potentially more enduring results. Traditional tools, such as case management and utilization review may still be used but in the context of an overall system approach designed to address the unique, economic clinical and resource requirements of specific diseases. The tools are not ends in themselves; they are merely building blocks in an overall disease management strategy. Disease conditions that have received the greatest amount of attention include asthma, congestive heart failure, diabetes, chronic back pain, cancer, and mental health care.

Whether or not the shift into this Disease Management paradigm can deliver on the promises or expectations of its effectiveness remain to be seen. To date, there are very promising results that seem to portend a very distinct shift in how the clinical practice of medicine and the entire health care industry is designed. As practitioners, we can expect this customer focus, integrated, proactive system of care to influence our clinical practices even more in the future.

July, 1998/ Jacksonville Medicine

 

What's New · Northeast Florida Medicine Journal · Know Your Physician · Legal & Legislative
· DCMS Alliance · Academy of Medicine · Member Websites · Community Health
About the DCMS · Meetings Calendar · Member Benefits · Employment Connection · Home

Duval County Medical Society   ·   555 Bishopgate Lane  ·   Jacksonville, FL  32204
Phone: (904) 355-6561   ·     FAX:  (904) 353-5848   
General Email: dcms@dcmsonline.org    ·   Webmaster's Email: mdoran@dcmsonline.org
Privacy Policy and Disclaimers