An HMO-Sponsored Primary Care-Based Disease Management and Case Management Initiative: Economic and Selected Clinical Outcomes
Franz Joseph Fisher
Objective: To describe the cost savings achieved in a health maintenance organization (HMO)-sponsored primary care-based case management and disease management programs. Methods: The HMO-sponsored programs recruited patients in the primary care setting and relied on clinical guidelines and HMO-employed patient education nurses and case management nurses. Total per member per month (PMPM) charges for medical services and changes in selected clinical outcomes before and after entry into HMO-sponsored case management and disease management programs for actively enrolled participants were compared during the fiscal year January 1, 1998 to November 31, 2000. Interventions: The disease management programs addressed asthma, diabetes mellitus and congestive heart failure (CHF). These programs were based on a network of primary care-based nurse educators and case managers promoting clinical guidelines, appropriate use of the insurance benefit, community-based resources, and communication among all healthcare providers. Setting and participants: This initiative was based in 55 primary care sites serving 295 000 insureds across northeastern and central Pennsylvania, USA. Results: 396 patients with asthma had mean baseline PMPM charges of $US298, which decreased to $US276 PMPM after entry. In those with diabetes mellitus, 3556 patients had a mean baseline PMPM charge of $US367 that decreased to $US346. The mean baseline PMPM charge decreased from $US1877 to $US1541 for 1795 patients with CHF. For 3346 patients undergoing case management, the mean baseline PMPM charge was $US1991 and it decreased to $US1545. Total mean reductions in claims over one year of follow-up from the day of entry for patients with asthma, diabetes mellitus, CHF and for case management programs were $US105 544, $US896 112, $US7 237 440 and $US17 907 992, respectively. Additional data regarding asthma-only claims and pre-post days of work loss in the previous six months, diabetes mellitus-only claims and pre-post mean glycosylated hemoglobin A1c values, inpatient and outpatient CHF total claims, ACE inhibitor use in CHF, and inpatient and outpatient total claims in case management are also provided. Conclusion: While these claims data may be limited by a lack of statistical significance and by regression to the mean, they suggest that case management and disease management programs in asthma, diabetes and congestive heart failure can be associated with significant financial savings compared with baseline levels of utilization. Clinical outcomes data also suggest this approach may be of benefit.
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