May 2, 2001

GAINING PHYSICIAN BUY-IN -- THE "ACHILLES HEEL" OF DISEASE MANAGEMENT
by Harry Leider MD, MBA

Why is achieving physician buy-in important to successful implementation of a disease management program?

It is my experience that programs that fail to gain widespread physician support have great difficulty enrolling patients and usually experience enrollment rates less than 40%. Conversely initiatives that enjoy strong physician sponsorship can achieve enrollment rates as high as 75%.
As a case in point, while I served as Medical Director of HealthNet (a regional managed care organization in Kansas City), we implemented both asthma and CHF programs at approximately the same time. The asthma program was provided by a disease management company with outstanding outcomes that invested little effort in achieving broad physician buy-in. Conversely, HealthNet worked with another firm to create a CHF program that actively engaged cardiologists and primary care physicians.

The enrollment rates were vastly different -- the asthma/COPD program rate was less than 50% while the CHF program's enrollment rate was over 80%. The CHF program had higher rates because cardiologists ACTIVELY referred patients to the program.

Why is achieving physician support so difficult? The core issue is that physicians inherently value autonomy. Disease management strategies SEEM to directly challenge the professional autonomy so valued by physicians.

In reality, most disease management programs don't supplant the central role physicians' play in caring for patient with chronic illness. Instead, they increase compliance with a prescribed regimen and monitor patients between visits to their physician.

So What Are the Core Tactics to Achieve Physician Buy-In?

Based on observing successes and failures of many programs that have tried to engage physicians, we have developed six core tactics for achieving buy-in for disease management programs. These are:

1) Providing Education
2) Enlisting Champions
3) Creating A "Box"
4) Building On Success
5) Sharing The Gains
6) Giving Them Tools

1) PROVIDING EDUCATION
Physicians need to be reassured that they will maintain their professional autonomy and central role directing the care of patients. Physicians generally respond positively when they review outcomes data from programs that have significantly improved quality of care and reduced costs.

Educational efforts must stress that good outcomes are achieved through a combination of good physician care supplemented by extra tools (e.g. patient education, compliance monitoring, electronic home monitoring, etc.) by the disease management program.

Considering the limited time most physicians can devote to learning about disease management, educational efforts must be varied in form and repetitive.

2) ENLISTING CHAMPIONS
Enlisting champions is a systematic approach to attain visible support from opinion leaders within a local medical community. Doctors make decisions in an autonomous fashion, but also respect the opinions of experts.

One effective approach to enlisting champions is to create a physician advisory committee for each disease management program. The role of the advisory committee can include providing input on: the decision to build vs. outsource the program, choice of a vendor, modification of clinical guidelines, patient identification, and effectively implementation tactics.
Most physician advisors become champions by becoming intimately involved with the program!

3) "CREATING A BOX"
Despite limited experience and infrastructure, often physician groups will refuse to support a disease management initiative unless THEY provide the program.

The tactic of "create a box" deals with this and has two basic elements. The first element is to articulate the value proposition offered by an experienced vendor. Having one or more companies present their programs to the interested group of physicians easily accomplishes this.

The second element is to use this data to create a set of criteria that the physicians must meet. For example, for congestive heart failure, a quality disease management company should be able to launch a program in 90 days, guarantee a 10% to 15% savings (net of the cost of the program), and deliver high levels of patient satisfaction. The physician group is then offered the opportunity to be the "vendor" if it can meet these criteria.

In most cases, provider organizations do not have the infrastructure to initially meet these criteria. Often, a compromise is reached where: 1) the providers agree to support the initial use of an outside vendor, and 2) they receive assurances that they can become the vendor when they develop the requisite competencies.

4) BUILDING ON SUCCESS
This is simple tactic whereby an organization demonstrates to physicians that earlier disease management initiatives have succeeded.
To execute this tactic it is important initially to target diseases where it is relatively easy to achieve good outcomes. For example, asthma and congestive heart failure are relatively easy programs to implement while HIV, diabetes, or low back pain are more difficult. Factors such as the presence of co-morbidities, involvement of multiple specialists, and presence of poorly aligned financial incentives make it more difficult to implement a disease management program for certain diseases.

Most physicians view a track record of successful programs as a persuasive argument to support a new disease management initiative.

5) SHARING THE GAINS
The goal here is to share the financial gains produced by disease management programs with the participating physicians. Organizations can do this in a variety of ways. Providing "case management fees" to physicians to compensate them for the time they spend interacting with care managers is one simple and effective approach. More complex financial schemes such as bonuses programs or "gain sharing" models can be used to create powerful incentives for physicians to support and participate in disease management programs. Finally, providing selected physicians a stipend for creating clinical guidelines or supervising care managers is another reasonable approach to sharing the gains.

6) GIVING THEM TOOLS
Disease management programs that make it easier for physicians to care for patients with chronic disease are usually well-received. Simple, well-designed patient specific reports, judicious interaction with case managers, data from electronic home monitoring devices, coordination of benefits or home services are all tools (or services) that support physicians in managing patients with severe chronic disease.

Many disease management vendors have deluged physicians with paperwork, faxes, phone calls, care plans, and guidelines. They have missed the boat on making life easier for the harried physician by providing tools and services.

PUTTING IT ALL TOGETHER
EVEN IF the tactics discussed above are used effectively, the process of achieving broad physician support is challenging and time consuming.
It is our experience that these tactics are most effective when they are employed by physician leaders who are CREDIBLE, PERSUASIVE, and PERSISTENT.

As mentioned earlier, the CHF program implemented by HealthNet employed ALL 6 TACTICS to achieve buy-in. Extensive educational initiatives included newsletters, lunch meetings, a physician advisory board and individual discussions with skeptical physicians. Initially several cardiology groups and hospitals felt that they could provide a CHF program. After they learned of "the box" of criteria that included guaranteeing savings and demonstrating outcomes, the cardiologists were open to working with a disease management vendor. Subsequently, cardiologists from the major groups were employed as medical directors for the program and supervised the program's nurse practitioners/case managers.

Primary care physicians and cardiologists were compensated with case management fees. This program also followed the successful launch of programs in asthma, COPD and high -risk maternity care.

Achievement of physician "buy-in" truly is the Achilles heel of disease management programs. Organizations implementing disease management programs should employ all of the six tactics outlined in this article. Ultimately, only organizations that are successful at working with physicians and achieving their support will achieve truly outstanding outcomes.

Contact Harry Leider, Principal, Better Health Technologies at harryl@bhtinfo.com or (410) 252-7361.

TRUCE! -- AMA, JCAHO, and NCQA AGREE ON COLLABORATIVE CLINICAL GUIDELINES

Who says cats and dogs can't get along? The American Medical Association (AMA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the National Committee for Quality Assurance (NCQA) have released collaborative guidelines on diabetes care.
AMA, JCAHO, NCQA News Release; April 25, 2001

Summary

"Coordinated Performance Measurement for the Management of Adult Diabetes" Consensus Statement

Commentary:
This is good medicine. The LACK of scientific, agree-upon clinical guidelines perpetuates fragmentation in US health care.

This is good business. While none of these three organizations INDEPENDENTLY has enough clout to issue guidelines that are likely to be accepted as standards, their issuing guidelines TOGETHER greatly increases probability of acceptance and implementation. Patients are better served when clinicians, delivery systems, and their accrediting organizations agree NOT to compete over clinical standards.

FINANCIAL INCENTIVES TO IMPROVE QUALITY -- HANDWRITING ON THE WALL

"Aide: Bush Medicare Reforms to Focus on Quality"
Reuters, April 12, 2001

Remarks from Dr. Mark McClellan, advisor to President Bush:

Some health care purchasers have already experimented with financial performance incentives to improve quality. For example, see "Financial Performance Incentives for Quality: The State of the Art"
National Health Care Purchasing Institute, September 2000

PAYOR MEDICAL MANAGEMENT APPLICATIONS

"Medical Management and the Internet: Views of Managed Care Leaders"
Cap Gemini Ernst & Young (CGE&Y), April 2001

CGE&Y interviewed information and medical management executives at 12 managed care organizations. Some of their major findings:

Commentary:
What's NOT at issue is the critical need for payors to enhance medical management strategies.

What IS at issue is the timing and phasing of implementation plans...this report does a good job of surfacing many of the complexities involved.

AD -- CHRONIC DISEASE STRATEGY WORKSHOP

The Institute of Medicine's (IOM) recent report advises that "Common chronic conditions should serve as a starting point for the restructuring of health care delivery."

Have your management team, board, or physicians wrestled with the potential upside and downside implications of ever-increasing chronic disease? Do you have a strategy in place?

More than 70% of medical costs are spent on patients with chronic conditions. "Chronic Disease Management: Bridging Clinical and Business Strategies" is a customizable workshop available for your organization. Faculty for this workshop are Harry Leider MD, MBA and Vince Kuraitis JD, MBA. 
Contact Vince Kuraitis at (208) 395-1197. 

ADVANCES IN DEPRESSION CARE

"Current Issues Report: Approaches to Depression Care. Health Plans' Innovative Programs in Depression"
American Association of Health Plans, March 2001

This report highlights health plan successes in depression treatment:

PERSPECTIVES ON E-HEALTH INVESTMENT OPPORTUNITIES

"Learning From Early Mistakes in E-Healthcare"
VentureWire, April 26, 2001

"Second Opinion"
FastCompany, April 2001

LINKS BETWEEN DIABETES AND PRODUCTIVITY

"Productivity Losses Associated With Diabetes in the U.S."
Diabetes Care, February 2001

CONCLUSIONS - Diabetes has a considerable net effect on earnings, and the complications and duration of diabetes have compound effects.... the presence of complicating factors is the single most important predictive factor in lost productivity costs attributable to diabetes, and thus the avoidance or retardation of complications will have an impact on indirect health-related costs.

FRAMEWORK FOR A NATIONAL HEALTH CARE QUALITY REPORT

"Envisioning the National Health Care Quality Report"
Institute of Medicine, March 2001

Commentary:
As important as this topic is, only the most dedicated reader will be able to stay awake -- all others should stick with the executive summary.

Disclosure -- No clients were mentioned this issue.



E-CareManagement News is an e-newsletter that tracks a major change in health care and managed care—the paradigm shift from “managing cost” to “managing care”.  This e-newsletter is brought to you by Better Health Technologies, LLC (http://www.bhtinfo.com).  BHT provides consulting and business development services relating to disease management, demand management, and patient health information technologies.

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