Disease Management and Wellness in the Post-Reform Era

Table of Contents

Foreword — David B. Nash, M.D., M.B.A. Dean, Jefferson School of Population Health

Introduction — Jill Brown, Executive Editor, AIS

Chapter 1: Disease Management of the Future and its Role in the Health Plan of the Future — Al Lewis

• The Future of DM and Wellness
• Other Future Trends
• The Role of DM in Health Plans of the Future
• What the Government Will Do to Facilitate Either Option

Chapter 2: Population Health Management and Health Care Reform — Tracey Moorhead

• Medical Loss Ratio
• Support for Wellness, Prevention and Health Promotion
• Delivery System Reform

Chapter 3: Disease Management and the Medical Home — Stephen Wilkins, MPH

• The Conceptual Origins of the Medical Home
• The Patient-centered Medical Home Defined
• What is Patient-Centeredness?
• The Evidence Supporting Patient-Centered Care
• The Case for Integrating Disease Management and the Medical Home Model
• What Will Disease Management Look Like in the Medical Home?
• Realizing the Potential of the Patient-Centered Medical Home — Key Enabling Factors

Chapter 4: Integrating Wellness Into the Health Care System — Richard Safeer, M.D.

• The Importance of Wellness in Chronic Disease
• Economic Considerations
• Role of Health Plans
• Mandated Preventive Services Coverage
• Culture of Health
• Addressing the Skeptics
• The Future

Chapter 5: Incentivizing People to Take Care of Themselves — Melissa Tobler

• The Evolution and Pervasiveness of Incentives
• Incentives Influence Behavior
• How Successful Are Incentives?
• Current Use of Incentives
• Health Care Reform’s Impact on Incentives
• The Future of Incentives

Chapter 6: Lessons Learned in Worksite Wellness — Al Lewis

• Lesson 1: All Wellness Programs Are Not Created Equal, so Pick the Program that Fits Your Culture and Budget
• Lesson 2: If You Build It, They Won’t Come
• Lesson 3: Make Wellness a Management Priority
• Lesson 4: Recognize and Overcome Organizational Impediments
• Lesson 5: Find Common Ground with Workers Compensation
• Lesson 6: Don’t Try To Change the World, Just Your Organization

Chapter 7: High-Impact Paradigms for Changing Behaviors to Enhance Health, Productivity and Well-Being — James O. Prochaska, Ph.D., and Janice M. Prochaska, Ph.D.

• High-Impact Paradigms for Changing Behaviors
• A Population Paradigm to Complement the Individualized Patient Paradigm
• The Action Paradigm Complemented by the Stage Paradigm
• The Passive-Reactive Paradigm Complemented by the Proactive Paradigm
• The Impact Paradigm Complements the Efficacy Paradigm
• The Home-Based Paradigm Complements the Clinic-Based
• Clinician and Computer Paradigms
• The Multiple-Behavior-Change Paradigm Complements Single Behavior
• The Coaction Paradigm Complements the Modular Paradigm
• The Integration Paradigm Complements Fragmentation

Chapter 8: Social Networking and Population-Based Health Management — Jaan Sidorov, M.D., MHSA

• What Is Social Networking?
• Implications of Social Networking in the Distribution of Health-Related Information
• Implications for Disease Management, Prevention and Wellness Programs
• Considerations for Care Management Programs in the Adoption of Social Networking
• Nine Considerations for Social Networking

Chapter 9: Emerging Insights about Measuring Disease Management Outcomes — Al Lewis

Chapter 10: Health Behavioral Economics — Murat V. Kalayoglu, M.D., Ph.D., and Peter Salovey, Ph.D.

• Cognitive Biases in Health Behavioral Economics
• Applications of Health Behavioral Economics in Disease
• Management and Wellness

Chapter 11: Care Coordination: Making the Most of Every Interaction — Kara Trott

• Missed Opportunities and Higher Costs Result From Fragmented Environment
• Intercepting Patients Early, Walking With Them Through the Process
• Measuring the Impact of Care Coordination
• Two Examples of Organizations That Have Made Care Coordination Work
• Improve Costs and Outcomes by Making the Most of Every Interaction

Chapter 12: Disease Management — To Build or Buy — David W. Plocher

• Strategic Considerations
• How Strategy Varies by Type of Service
• How Strategy Is Affected by Service Contents
• The Past Five Years
• Current Market Requirements Influencing the Decision
• When Is Outsourcing the Better Option?
• Is There a Middle Ground? Licensing Pieces of DM Company Product Inventory
• What’s Next?

Chapter 13: How to Start an Internal Medicare Disease Management Program — Scott Breidbart, M.D., and Lorraine McDonald, R.N.

• Why Start an Internal Disease Management (DM) Program?
• Define the Population
• Time to Go Live
• Program Scope
• Member Identification and Stratification
• Clinical Program Content
• Recruiting and Staffing
• Clinical System
• Telephony
• Member and Provider Materials
• Future Directions in Medicare DM

Chapter 14: Your Future’s in the Stars — Molly Doyle, MBA, and Sarah Baker

• Some History on Medicare Advantage
• CMS Star Ratings
• CMS Announces Changes to Star Ratings
• Proposal to Accelerate and Expand Bonus Payments
• A View From the Top
• Assembling Your Team
• Getting Started
• Plan of Attack
• Looking Ahead

Chapter 15: What Disease Management Executives Need to Know About Risk-Adjusted Medicare Reimbursement — Zach Gerbarg, M.D., CPC

• The Development and Impact of Risk-Adjusted Reimbursement
• The Physician Challenge in Risk-Adjusted Reimbursement
• Retrospective ICD-9 Code Capture Programs and Their Limitations
• The Growth of Prospective ICD-9 Code Capture Programs
• Steps to Implementing a Prospective Severity-Adjustment Documentation and Coding Program to Improve Care
• Integrating Prospective Programs into Medical-Management Activities
• Nursing Home and SNF Case Study

Written By

• Al Lewis is President of The Disease Management Purchasing Consortium International, Inc., based in Wellesley, Mass.
• Tracey Moorhead is president and chief executive officer of the Care Continuum Alliance, which convenes all stakeholders providing services along the care continuum toward the goal of population health improvement.
• Stephen Wilkins, MPH, is the principal and founder of Smart Health Messaging.
• Richard Safeer, M.D., F.A.A.F.P., is Medical Director, Preventive Medicine at CareFirst BlueCross BlueShield.
• Melissa Tobler, RN, BSN, is the national practice leader for health strategies at Hays Companies.
• James O. Prochaska, Ph.D., is director of the Cancer Prevention Research Center and a professor of clinical and health psychology at the University of Rhode Island.
• Janice M. Prochaska, Ph.D., is president and chief executive officer of Pro-Change Behavior Systems, Inc., based in Kingston, R.I.
• Jaan Sidorov, M.D., MHSA is a seasoned primary care physician with a working familiarity with health insurance, corporate governance, health service research, disease management and health care quality. He runs the Disease Management Care Blog, is the author of over 35 peer-reviewed publications, and a presenter at 60 health conferences.
• Murat V. Kalayoglu, M.D., Ph.D. is Chief Science Officer at HealthHonors – a Healthways Company.
• Peter Salovey, Ph.D. is the Provost of Yale University and the Chris Argyris Professor of Psychology.
• Kara Trott is founder and CEO of Quantum Health, Inc., based in Columbus, Ohio.
• David W. Plocher, M.D., is vice president of Ingenix Consulting, providing services to payers and providers on strategic collaboration, payment reform, health management and performance measurement.
• Scott Breidbart, M.D., is manager, medical director at Indianapolis-based WellPoint, Inc.
• Lorraine McDonald, R.N., has extensive experience in development of internal disease management programs. She is currently senior director of Medicaid clinical programs for a large national payer organization.
• Molly Doyle, MBA is vice president of product management at Health Dialog.
• Sarah Baker is product manager for senior products at Health Dialog.
• Zach Gerbarg, M.D., CPC is principal and co-founder of Eagle Medical Management, LLC, a health care consulting firm with particular expertise in diagnosis documentation and coding for risk-adjusted reimbursement.

Written For

• Health plan executives
• Disease management company executives
• Employer groups
• Employee benefit managers
• Coordinators of state health programs
• Pharmacy benefit company managers
• Pharmaceutical industry managers

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