Health care law expands requirements for disease management
In 2008, Barack Obama promised to reform health care.
One of his many health care promises included a pledge to require health insurers to use disease management programs to lower costs. Health plans in a new "public plan,” in Medicare or in the Federal Employee Health Benefits program would all have to participate, he said.
"Disease management” covers a wide range of programs to help people with chronic diseases better coordinate their health care. HealthReformGPS, a project of George Washington University, has an excellent primer.
It turns out that the president's 2010 health care law, the Affordable Care Act, includes a range of provisions to encourage disease management.
But are those programs now a required part of plans in health exchanges, in federal employee plans and in Medicare?
(Since Obama's public option never materialized, we're looking at requirements for private plans offered on new health care exchanges that launch in 2014.)
Here's what we found:
Health exchanges: Yes. The Affordable Care Act requires plans to cover a set of "essential benefits.” While some details will be set by states, the law requires that those benefits include "preventive and wellness services and chronic disease management.” So, except for grandfathered plans, which aren't yet required to offer essential benefits, some disease management services are required.
Medicare: Yes. Medicare and Medicare Advantage plans cover some disease management services, such as behavioral therapy for patients with cardiovascular disease and obesity, according to the Centers for Medicare & Medicaid Services. In addition, the health care law created the Center for Medicare and Medicaid Innovation to test new ways to improve care and save money, which may widen use of disease management programs. The models it's testing "strongly emphasize management of the chronically ill,” according to HealthReformGPS. (However, we should note that evidence so far shows that few disease management programs offer the expected Medicare savings, according to a paper published by Kaiser Family Foundation.)
Federal Employee Health Benefits: No. The government's latest requirements for health plans offered to federal employees say they "expect” insurers to offer programs "that promote health and wellness and which are aimed at improving employee productivity, enhancing healthy lifestyles, and lowering long-term health care costs.” That includes incentives for employees who adhere to disease management programs. But the guidelines stop short of requiring health plans to offer such programs.
In 2008, Obama promised to require that health plans use disease management programs to improve efficiency and lower costs. While his health care law includes a variety of provisions to support and expand disease management, such programs aren't yet required for federal employee health plans. Nor are they proving as effective at lowering Medicare costs as once hoped. We rate this promise a Compromise.
Email interview with Timothy Jost, professor at the Washington and Lee University School of Law, Jan. 10, 2013
Email interview with Isabella Leung, spokeswoman for Centers for Medicare & Medicaid Services, Jan. 14, 2013
Email interview with Lindsey O'Keefe, communications & public liaison, Office of Personnel Management, Jan. 14, 2013
Government Printing Office, The Patient Protection and Affordable Care Act, March 23, 2010
HealthReformGPS, Chronic Disease Management, Feb. 23, 2011
Congressional Research Service, "Federal Employees Health Benefits Program (FEHBP): Available Health Insurance Options," Nov. 6, 2012
U.S. Office of Personnel Management, The 2013 Guide to Federal Benefits For Federal Civilian Employees, revised November 2012
U.S. Office of Personnel Management, FEHB Program Carrier Letter, March 29, 2012
HealthReformGPS, "Update: Essential Health Benefits FAQs," May 9, 2012
HealthReformGPS, "Update: Essential Benefits," Dec. 20, 2011
HealthReformGPS, "Essential Benefits," Jan. 12, 2011
Kaiser Family Foundation, "Essential Health Benefits: What Have States Decided for Their Benchmark?" Dec. 7, 2012
Kaiser Family Foundation, "Best Bets for Reducing Medicare Costs for Dual Eligible Beneficiaries: Assessing the Evidence," October 2012
Centers for Medicare & Medicaid Services, "National Coverage Determination (NCD) For Intensive Behavioral Therapy For Cardiovascular Disease,” Nov. 8, 2011
Centers for Medicare & Medicaid Services, "National Coverage Determination (NCD) For Intensive Behavioral Therapy For Obesity,” Nov. 29, 2011
Pilot program includes disease management
During the presidential campaign, Barack Obama included disease management among his ideas for improving health care and lowering costs. Disease management is intended to improve outcomes for people who have chronic illness. It emphasizes prevention, including enhanced screening, monitoring and education and coordinating care among different health care providers.
Health care reform bills being considered by Congress mention disease management in the context of a pilot program called medical homes. You don't live in a medical home. They are — sorry for more medical jargon here — primary care practices that emphasize continuous, family-oriented care. Typically, they emphasize prevention through electronic health records, careful tracking of patient outcomes, and superior doctor-patient communication.
The health care bills establish and expand medical homes for Medicare, the national health insurance program for the elderly, and the bills specifically mention disease management as an aspect to be included in the new programs.
A few warnings here: It's not clear that disease management programs save money. And a pilot program is a far cry from all health plans. This promise seems like one more likely to be implemented after other, more significant health care reforms come first. But it is a start. We'll see if the trend spreads. For now, we rate this promise In the Works.
U.S. House of Representatives Energy and Commerce Committee, HR 3962 - the Affordable Health Care For America Act
U.S. House of Representatives Ways and Means Committee, HR 3962 - Section by Section
Congressional Budget Office, An Analysis of the Literature on Disease Management Programs , Oct. 13, 2004
The Commonwealth Fund, Can Patient-Centered Medical Homes Transform Health Care Delivery? , March 7, 2009