Disease-Based Programs as Solutions to Population Health

Disease-based programs grew in momentum in the 1990s as a tool to improve care for patients with chronic disease while identifying and reducing high-cost and low-value care events. Usually, disease-based programs are focused on how to keep people healthy and out of the hospital; it may not always be “top of mind” to think about disease programs as a means of program growth and stability. It is helpful to understand the basic goals of a chronic disease program in order to connect the potential impact on program growth and clinical benefits.

DISEASE-BASED PROGRAMS

Chronic disease programs develop by identifying the following measures:

• Definition of disease—inclusion criteria
• Financial impact—cost per beneficiary
• Pattern of use—frequency of high-cost events, admissions, and emergency department (ED) visits
• Demographic area—age, sex, and economic status
• Intended benefit impact—achieved with care paths and practice standards

There are many disease-based programs currently operating; in order to highlight the link between a disease-based program and new program growth, this article focuses on heart failure. Heart failure disease programs have been an early focus for cardiology due to value-based readmission penalties and rewards. Although other disease-based programs were developed, heart failure was unique in that the financial impact of reducing high-cost readmissions was a proven result. It could be argued that even without the prompting of value-based purchasing, the heart failure patient population was a prime candidate for disease management due to the high volume, high cost, and variation in treatment that existed. For many, it seems intuitive that a heart failure disease-based program would be a critical part of population health management. But how does a disease program affect growth, and potentially, cardiovascular procedures?

Program growth has been a long-standing goal in the United States health care system. Despite the movement from volume to value, program growth continues be a strategic focus for many systems—especially those providing high-end cardiovascular therapies. High-cost and new therapies, such as ventricular assist devices (VADs) and transcatheter aortic valve replacement (TAVR), require a foundational volume to maintain a referral base, operator skills, and care team exposure. This equates to overall program volume and strong referral relationships. What must look different in this new value model is not solely growth in procedure numbers but rather the ability to bring the right patient in at the right time for the right procedure. A high-functioning disease-based program can provide this level of coordination. Whether the team members are called a disease management team or team-based care, the goal of utilization is joined.

KEY COMPONENTS

There are some key components to a high-functioning disease management team:

• Inclusive facilitator
• Defined stakeholders and objectives
• Respect and trust
• Nimble response to change
• Accountability for objectives
• Virtual participation
• Continuous education and feedback

Consider the elements about how this heart failure disease management team would support the new VAD program. An inclusive leader is essential because the team can involve the primary care physician, noninterventionist, heart failure specialist, cardiovascular surgeon, anesthesiologist, intensivist, care manager, operating room leadership, and nursing leadership in case selection. This level of connection ensures that patients are offered coordinated workups and options at the right time in the disease process. It begins to paint the picture of a coordinated plan for appropriate utilization of not just the VAD implant but also the key decision points and resources leading to the decision and care after implantation.

There is a strong need for clear objectives, including the number of cases reviewed, the percentage or stakeholders involved in the review process, and the time from decision to implantation. The team must be aligned and incentivized to achieve the objectives and must be accountable to change direction as needed to achieve outcomes.

The use of virtual meetings is very helpful for this diverse group. Systems that can leverage technology will see greater participation, as getting primary care physicians to attend on-site hospital meetings may be a significant barrier to this required role.

In addition to the clinical team responsible for the decision to implant, there is considerable community education that must occur. VAD programs require emergency medical services, EDs, subacute care, pharmacy, community hospital, and rehab education resources and it is the responsibility of the program facilitator to ensure this education occurs.

What does it look like when a program embarks on a new technology, such as a VAD program, without an advanced care team in place? These programs frequently do well for one or two quarters. There is generally a pent-up need for the device that originally fuels the decision to implement the VAD program. These programs have a small team of physicians directly involved in the procedure that determines the appropriateness of the patient moving forward with the device. So far, there does not seem to be a significant growth difference between a fully inclusive advanced care team and a smaller focused care team. The difference appears as the referral base dries up or referrals are poorly coordinated. This happens because the physician community has not been educated on the new device, the primary care physicians do not know how or when to access the program, and the program is entirely dependent on the performing physician’s unique patient panels.

Another frustration to the VAD team is receiving patient referrals too late or early in the disease process. This wastes the time of the team and negatively affects the perception of the patients and referring physicians. Think about the more inclusive model, where referring physicians and other key care providers can participate in virtual treatment reviews. This venue allows for real-time education and discussion by all members in the patient’s care.

Assessing new technology may look very different in tomorrow’s value model than it does in today’s volume model. Today, every heart program looks to add new technology with the concern of “if we don’t participate, we will risk losing volume and revenue.” In tomorrow’s model, it may be more realistic to first look at your population and ask if there is a need for this service. Is the service being met today within a reasonable geographic area? If the high-cost, low-volume new technology is currently being offered in a high-quality, low-cost setting, it may not be the best decision to compete with the new technology. Those responsible for a patient’s care costs may worry less about offering the services than directing the patient to a low-cost, high-quality program, specifically when considering new technology that has low volumes and high costs. However, should the care team determine there is an unmet community need, the next question should be: “Are the resources available to manage the care continuum for these patients?”

SUMMARY

To embark on a program such as VAD implants, there must be a strong advanced heart failure program in place prior to considering the procedural needs of a VAD device. An easy mistake to make is viewing a single office or acute care center heart failure program, focused on hospital readmissions, as an advanced heart failure program. A disease management program must run much deeper. The focus is population need and utilization objectives. If a disease program is well designed, easy for caregivers to access, and provides education and feedback, the result will be a fiscally sound program designed for purposeful growth.

Anne Beekman, RN
Vice President
MedAxiom Consulting
Neptune Beach, Florida
abeekman@medaxiom.com
Disclosures: None.

Ginger Biesbrock, PA-C, MPH, MPAS, AACC
Vice President
MedAxiom Consulting
Neptune Beach, Florida
gbiesbrock@medaxiom.com
Disclosures: None.