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Disease management at Kaiser Permanente: Dramatic health improvements and savings when compared to the medical trend
By Paul Wallace, MD
Executive Director of Kaiser Permanente's Care Management Institute
As our nation grapples with how best to provide "value" to health care consumers, Kaiser Permanente can make the following claims with pride:
- Kaiser Permanente's approach to disease management has achieved dramatic health improvements for our members with chronic conditions and has saved money compared to the medical trend.
- Disease management isn't a "program" at Kaiser Permanente: It is our way of practicing medicine.
In cardiovascular care, for example, heart disease is no longer the number-one cause of death in Kaiser Permanente's Northern California Region. Focused efforts in managing heart disease have decreased mortality to such an extent that is the second-leading cause of death, following all cancer. This is in contrast to the rest of the country, where heart disease is the leading cause of death.
Kaiser Permanente members with diabetes have had great success in controlling their cholesterol levels – and improvement of 119% between 1998 and 2003 (most recent data available). This is critically important since both diabetes and elevated cholesterol levels translate into a two- to four-times increased risk for heart attack and stroke. If these improvements are sustained over just five to six years, 4,900 heart attacks or strokes would be prevented. Kaiser Permanente has also seen major improvements in blood pressure control in diabetic patients between 2001 and 2003. Blood pressure control is even more important than LDL-C in managing diabetes.
Our disease management program provides value
Kaiser Permanente provides quality care, while at the same time providing value for our members' health care dollars. Kaiser Permanente's approach to disease management saves money compared to trend.
Using methods commonly reported in the disease management industry, we could say that Kaiser Permanente's disease management programs have saved $200 million in the most recent study year among patients with four chronic diseases in Northern California . This cost savings was accompanied by dramatic health improvements for the populations of patients with heart failure, heart disease, diabetes, and asthma.
We believe in total health and prevention
Because Kaiser Permanente believes in total health and prevention, we have implemented programs to help prevent our members from ever developing chronic conditions in the first place. We believe that implementing the latest evidence-based medicine is the best way to improve the health of our members with chronic conditions.
The emphasis on prevention and wellness has been our approach to disease management for the past five decades. Kaiser Permanente's disease management activities have always been an essential, built-in, embedded part of its basic delivery system. Disease management is not a "new" program that Kaiser Permanente has added in only the last few years.
We take a systematic, coordinated approach
We also have implemented a systematic, integrated, coordinated approach to management of chronic conditions because chronic illnesses cause the greatest suffering and the highest costs of care for our members.
- For example, just under 9% of Kaiser members--representing over 500,000 individuals--have diabetes. Over 6% have depression, and nearly 4% have coronary artery disease. Asthma (2.1%) and heart failure (1.4%) also affect many members. In fact, we coordinate care for approximately 1,120,000 Kaiser members -- 16.1% of total enrollment -- who have one or more of the common chronic conditions, diabetes, heart disease, asthma and depression.
- Among our non-Medicare members, individuals with chronic conditions account for two-thirds of all costs, and the share is significantly higher for our Medicare members.
We use advanced technology to manage chronic conditions
In addition, Kaiser Permanente uses advanced clinical information technology to manage chronic conditions. Kaiser Permanente is currently investing in a new, $3-billion comprehensive information system called KP HealthConnect which will lead to further quality improvements in managing chronic conditions because the system:
- Provides physicians and other clinicians with better information on patients with chronic conditions and enable Kaiser Permanente to rapidly implement the latest in evidence-based medicine through clinical guidelines and powerful decision support capabilities.
- Provides members with greater access to their own health information and enable them to provide better self-care.
- Provides Kaiser Permanente's researchers with an unprecedented ability to study the health of chronic disease populations and accelerate our learning about how to provide the best possible care to our patients.
- Will eventually provide Kaiser Permanente with an unprecedented ability to provide purchasers with detailed information on the quality and cost of care for their patients with chronic illnesses.
Absolute cost savings?
Several recent research publications have tried to measure absolute cost savings for disease management programs. A November 10, 2004, Health Affairs article, written by Kaiser Permanente researchers Bruce Fireman, Joan Bartlett, and Joseph Selby, MD, using Northern California data, looked at cost savings in two different ways.
The paper fond no evidence ofabsolute cost savings year over year, largely because of double-digit annual increases in technology and drug costs that have increased health care costs for the entire patient population as well as chronically ill patients.
Other papers have drawn similar conclusions. In a report dated Oct. 13, 2004, the U.S. Congressional Budget Office (CBO) concluded that "there is insufficient evidence to conclude that disease management programs can generally reduce overall health spending."
The Health Affairs article did point to a possible relative cost savings of $200 million in the most recent study year among patients with four chronic diseases in Northern California , if we apply an analysis based on commonly used industry methods and assumptions which measure costs against trend.
The relative change in cost, which is a commonly used method in the industry, compares the actual 2002 average cost with what the 2002 average cost would have been in the absence of disease management programs – in other words, comparing actual cost against the cost trend that KP would have experienced without its disease management interventions.
Substantial quality improvements
The Health Affairs authors also found that disease management programs led to substantial quality improvements from 1996 to 2002 for adults with coronary artery disease, heart failure, diabetes, and asthma in Northern California.
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