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Disease Management

A changing landscape calls for innovation in commercial health plans


For decades, health plans have run programs, referred to as disease management (DM) or chronic condition management programs, which target patients with chronic diseases and attempt to educate and support those who are most critically ill and those for whom intervention is likely to have an impact. While health plans are in a unique position to help, they also face economic and political pressures and changing employer/purchaser demands to do so, which influence the scope and focus of the programs they provide. Even as the value provided by health plans is being questioned, health plans remain on the front lines, trying to manage costs and utilization.

Since many DM programs have had mixed success, health plans should consider re-evaluating how they approach DM and member services to find opportunities to deliver real value.  We believe five trends in medical management have the potential to change the equation for health plans as they design DM programs in the future:

  • The growing burden of care
  • Challenges to traditional DM business models
  • Emerging care delivery models
  • Slow downs in medical management strategy and program development
  • Increased emphasis on the medical home model

Together, these trends suggest three critical implications for health plans as they move toward the next generation of health care. They should consider:

  • Evolving to a more holistic approach to disease management
  • Creating clear value propositions, supported by measurable outcomes, for their DM programs
  • Remaining flexible to the needs and dynamics of the customers of the industry which would include employers, Medicaid, Medicare and individual consumers

The competitive landscape for health plans is changing. Successful plans will be the ones that translate these dynamics into actionable strategies that result in an increase in the depth and success of their programs.

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