Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. C. Disease Management and Other Assistance Programs


Disease management programs typically assist people who have a single or dominant condition, generally chronic, and entail processes for identifying patients, educating them or their doctors on the management of the condition, and using ongoing monitoring. In many ways, disease management programs vary along the same dimensions as care management programs. Thus, the programs differ primarily in terms of how comorbidities are handled, whether there are face-to-face interactions with the patient, the relationship to the primary care physician, and the extent of the focus on medication compliance. Addressing medication issues is easier if the plan covers prescription drugs and thus has access to a database that describes the medications received by each patient. Such a database can help the organization assure that medications are used effectively.

All the disease management programs at our case study organizations were created internally, although such programs can be purchased from a pharmaceutical company or a freestanding company. The MCOs did not make age distinctions (for example, elderly or nonelderly) in determining eligibility for disease management, although some conditions (such as congestive heart failure) are particularly prevalent among elderly people. The case study organizations had programs relating to heart disease, diabetes, depression, and joint replacement, among others. What is described below are only examples; many of the programs were of recent origin at the time of our visit and were still evolving.

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