Money and Medicine; Bedside Visits, on the Telephone

After checkups at the Staten Island Medical Group, Albert Agate used to say, "I should have asked my doctor this; I should have asked my doctor that." But the waiting room would be crowded, and the doctors often seemed pressed to move to the next patient.

"They were not giving me that time that you need," he said.

Now, Mr. Agate, 66, a retired postal worker with diabetes and heart problems, can present his questions by telephone to Joanne Anderson, a registered nurse who knows his case and calls him regularly to advise him about diet and medications. "Joanne will sit with me on the phone for 45 minutes," he said. "She always has the answer."

Ms. Anderson works for CorSolutions Inc., a company in Buffalo Grove, Ill., that is one of dozens in a fast-growing and sometimes controversial business called disease management. These companies provide information and advice to hundreds of thousands of patients with serious medical conditions, including asthma and depression, and especially to those with multiple maladies.

Most health plans have had programs, of varying size and effectiveness, that have aimed to keep their members healthy enough to stay out of hospitals. But companies specializing in disease management have thrived in the last year or so as plans have retreated from cost-cutting measures that deny or delay care, upsetting patients and physicians.

As they signed up Blue Cross plans, employers and other insurers, revenue for disease management companies rose 39 percent last year, to $485 million, versus $350 million in 2000, said Al Lewis, a consultant in Wellesley, Mass., who helped negotiate some of the health plan contracts for the companies.

Aetna (news/quote), for example, one of the largest managed-care companies, hired American Healthways (news/quote), based in Nashville, and LifeMasters Supported SelfCare, of Irvine, Calif., last year to help patients with congestive heart failure avert repeat attacks.

Dr. John W. Rowe, chief executive of Aetna, said there had been "a fundamental change" in managed-care methods, which have included restricted networks of doctors. "Those tools have lost their power," he said. He sees the new services as adding value for doctors and patients and taking managed care "beyond being a fiscal intermediary, which managed cost much more than it managed care."

The advice and monitoring is particularly useful for patients with more than one medical problem. People with diabetes who are clinically depressed "use three times as much health care in a year as those with just diabetes alone," said Dr. Paul Wallace, executive director of the Care Management Institute at Kaiser Permanente, the big California-based network of doctors, clinics and hospitals.

But some doctors criticize the disease management approach. "Once you have a third party in there who has never seen the patient" and is working from computerized instructions, "there is the potential for cookie-cutter management that may not be of benefit to the patient," said Dr. William J. Hall, an internist in Rochester who is president of the American College of Physicians-American Society of Internal Medicine.

Warren Todd, executive director of the Disease Management Association of America, a trade group in Washington, said: "We antagonized the doctors. We sent letters to doctors that said, `We are now managing your patient.' "

But both sides are trying to bridge the gap. The disease management companies say they have been making an effort to work more closely with doctors.

Mr. Lewis, the consultant, said many doctors had come to accept the disease managers as an extension of their practice, not as an intrusion.

Dr. Archelle Georgiou, medical director of the United Healthcare division of the UnitedHealth Group, says the company's disease-management program tries "to be the eyes and ears for the physician."

The insurers and disease management companies have statistics to trumpet their effectiveness - "11 percent more children with asthma sleeping through the night," for example, from UnitedHealthcare.

But Dr. Carolyn Clancy, a research director at the federal Agency for Health Care Research and Quality, which monitors health care disparities, said that there was "very little evidence" to prove the effectiveness of care by software and telephone. "We are encouraging more research," she said. "It is very much needed."

The National Committee for Quality Assurance, a nonprofit group that accredits health plans and care providers, has started evaluating disease management companies. Next year, it will require them to use standardized effectiveness measures. Margaret O'Kane, president of the quality-assurance group, said disease management was not a complete solution to the rising costs of health care. It is "not enough to contain the costs on the scale they need to be contained," she said.

But Mr. Agate in Staten Island appreciates the help. He had quadruple coronary bypass surgery after a heart attack four years ago and later developed Type 2 diabetes, a common combination that lands many patients in the hospital. "I could use all the help I can get," he said.

© 2009 Care Management Institute