The Disease Management Care Blog, based on vast experience, occasional consulting gigs, the peer-reviewed literature, informed opinion and late-night beverage-fueled conversations is pleased to offer this seven-step Recipe for Making Money With Disease Management:
1. First off, notify the physicians about your plans using a variety of communication channels such as meetings (food helps), memos emails and announcements. Establish an physician advisory committee and reward them for their effort. Most importantly, never ever ask any physician anywhere to alter his or her clinical work flows. Set aside.
2. Next, identify the population. This may be all persons in a service area, employees plus dependents, those being served by a clinic, having a particular diagnosis or assigned to an Accountable Care Organization.
3. Obtain one nurse for between every 800 to 1500 patients in your population. Leaven with primary care experience, top of license, connectivity, protocols, mobility, telephonic as well as face-to-face patient coaching and a full time dedication to the task at hand. Avoid hiring refugees fleeing the ICU 11-7 shift. Set aside.
4. Knowing that as a covered entity that you will protect personal health information, obtain, array and organize all available clinical and/or insurance claims data on that population. This may involve mining an EHR, extracting insurance claims information or conducting a health risk survey. Place on a server or a cloud.
5. Applying a variety of statistical methodologies to the data, risk segment the population for an outcome of interest such as (but not limited to) hospital admission, high expense or high primary care use. Mix thoroughly. This will allow you to identify those individuals at greatest future risk.
6. Return to the nurses. Assign one nurse to one or more physicians (or clinics) and have the nurses contact and assess the patients in those clinics who are highest risk. For those with modifiable risk, engage, educate, coach and collaborate. For those without modifiable risk, discharge, refer and move on.
7. Nurse-physician collaboration should achieve physician buy-in and patient betterment. Physicians with constructive input should be referred to the committee in described Step 1 above. Nurses should also experience an appreciable case-load turn over as patients graduate and more are recruited to take their place.
This recipe should lead to the following return-on-investment (ROI) curve:
Since there are high up-front fixed costs, early enrollment savings will not match start-up costs. As the highest risk opportunities are realized, the ROI will turn positive. However, as nurses continue to enroll patients at progressively lower risk, the likelihood of modifying future costs, hospitalizations or utilization will diminish and eventually result in a negative ROI. The idea is to limit the program to the patients at greatest need and stop while you're ahead.
Let the DMCB know if you want the graphic on a PowerPoint slide.