Disease Management and Medicaid Waiver Services for HIV/AIDS Patients. Introduction


Disease management (DM) refers to a system of coordinated health care interventions and communications to help patients self-manage their chronic diseases and prevent complications from these health conditions. DM has been touted by vendors as an effective tool to reduce health care costs. Some DM vendors have claimed that disease management programs can save as much as eight times the cost of the program. Vendor marketing materials refer to overall program savings, per member per month savings, or reduced annual health care expenses. Marketing this sort of “return on investment” has piqued strong interest in DM among private and public payers of health care services. However, it has not been conclusively determined that DM can successfully reduce the costs of care or significantly improve health outcomes, particularly among individuals with multiple chronic conditions.

DM is commonly offered in private insurance plans and employer-sponsored wellness programs, and Medicaid and Medicare have incorporated DM approaches for some enrollees. Questions remain about the elements of DM that improve patient outcomes and whether DM can effectively reduce costs of care for certain populations. When high-cost patients are targeted for DM, measuring outcomes is challenging because it is difficult to attribute the intervention with producing an effect that may have occurred even in the absence of the intervention.

This paper examines the limited evidence to date on the impact of DM for low-income populations enrolled in public insurance programs, and raises questions about the effectiveness of DM targeted to HIV/AIDS. An important question is whether DM is a useful approach for health care delivery even if it does not reduce the costs of care. The capacity for DM to reduce the costs of care for complex medical conditions like HIV disease may be limited, but more research is needed to assess the extent to which DM offers value in dimensions of quality such as improving care delivery, clinical outcomes, patient satisfaction and quality of life. The growing trend of using DM in Medicaid may yield information about how such approaches can benefit vulnerable populations with chronic conditions and possibly make the case for expanding DM as an intervention within other programs for population health improvement. In the current climate of unsustainable health care cost growth, any increased costs resulting from the adoption of DM are worth close examination.

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