Question

Discuss the emerging role of Disease Management (DM) and Intensive Case Management in American managed health care programs. How does Disease Management actually work?

Answer 1

Ans) Overall, both case management (CM) and disease management (DM) are vital to reduce healthcare costs by helping beneficiaries control their disease and prevent excessive utilization. However, there are differences in their approach.

- DM can improve quality care for members with chronic disease. It facilitates healthy lifestyles by focusing on prevention (eg, modifies risk factors), reducing hospitalization (eg medication adherence), and healthcare access. CM improves quality and patient experience by coordinating hospital care. It ensures that the hospital care utilizes the least restrictive & clinically appropriate alternatives. CM is tailored to the individual and focuses on a single patient; DM is meant for the population, using an integrated, and multi-level approach. DM is for all health plan members, tailored particularly to the 15% to 25% of members at high risk.

- DM involves early identification for members in all stages of disease (primary to tertiary prevention). Participants typically have moderate acuity levels. DM programs are offered through the health plan or at the IPA/medical group/physician level. For DM programs, unlike CM, there is no need to change plan design.

- Interventions can take place at any time of the year (365 days), in work or at home; CM is usually episodic care, from 60 to 90 days. CM is offered in hospital clinics, home health agencies, health plan environments, and subacute facilities.