Disease Mangement

DM Firms' Role in Home Care Now Is Minor, But May Grow With Rising Role in Medicare

Reprinted from the Sept. 23, 2005, issue of INSIDE DISEASE MANAGEMENT.

Disease management (DM) companies typically emphasize telephonic, Web and mail-based interventions over face-to-face visits with patients. But sometimes, in-person meetings are necessary — and likely will become more common, as Medicare beneficiaries account for a larger proportion of DM enrollees. To provide these services, DM firms typically do not contract with home health agencies, however, instead relying on internal staff members or those of partners.

Industry executives and experts say Medicare beneficiaries who have significant health or communication challenges or are based in institutions rather than the home are the most likely to benefit from face-to-face DM visits. Medicare DM programs for that population are growing rapidly as a result of the Medicare Health Support pilot and the new requirement for Medicare Advantage plans to provide DM services starting Jan. 1, 2006.

"The role [of home health care in DM] is very, very minor," says Al Lewis, president of the Disease Management Purchasing Consortium. "There are a few vendors, such as AirLogix [Corp.], that do home visits routinely." That is a change from the DM industry's early years, he contends. "It was found that they [i.e., home health care services] fostered a dependency as opposed to providing education and self-help."

DM industry executives say their job is to help patients with chronic conditions learn to better manage their care — not to provide in-home patient care, which would be duplicative to the services already provided by home health agencies.

"In our model, we're facilitators, not deliverers," says Tamara Hall, a senior vice president at Health Dialog Services Corp. "We do face-to-face interactions in the home or potentially the hospital." But, she adds, these visits are "not a substitute for in-home care."

"We do have respiratory therapists that go into the home — but we don't do home care services. We do DM," says Susan Riley, CEO of AirLogix, a respiratory DM firm that recently became a subsidiary of Centene Corp. AirLogix uses its own staff members to perform these in-home visits in order to ensure "consistency and quality," Riley says.

She notes that when AirLogix starts providing DM services for a population, "we actually increase [the percentage of the population getting] home health services from 2% to 4%. The reason is that we're getting people out of the hospital and into the home — and our customers are happy. That's what they want to see happen." Generally, the physician refers the patient to home health services, and home health agencies contract directly with the health insurer or other payer.

American Healthways, Inc. used to include home health visits as part of its respiratory program, but discontinued them, says Bob Stone, the firm's co-founder and executive vice president. "The reality is that over the years, physicians have forged very strong relationships with home health agencies that they rely on," he contends. "And in most cases, either the health plan or Medicare pays for qualified home health care. So there really is no need for us to interject in that relationship or try to bring a substitute to the market."

Health Management Corp. (HMC) used to own a home health agency, Healthy Homecomings, which specialized in women's services, including pregnancy and post-partum care, says Donna Snow, the DM firm's director of operations. The company purchased the agency in 1995 and closed it in December 2004. "The number of visits that we were doing was definitely decreasing, mainly because it was a very specialized agency," she explains. "We were losing money."

Medicare DM May Use More Home Health

Some DM executives predict that utilization of home health visits by DM firms will grow as more companies serve Medicare beneficiaries.

Medicare DM is "an exception" to the rule that there is not much of a role for home health in DM, Lewis says.

Reaching Medicare patients can be challenging, Riley says. "Getting.services [to Medicare enrollees] in the home can be pretty difficult," she explains. "They're going to need to have some sort of home presence."

"There is a subset of the Medicare population, especially those with frailty or communication [issues], where face-to-face visits become a more effective means of support," Hall says. Health Dialog, a Medicare Health Support awardee, on Aug. 1 started providing DM services to Medicare fee-for-service beneficiaries in Pennsylvania. Face-to-face visits are conducted by Health Dialog staff members or those of ParadigmHealth, Inc. or Magellan Health Services, Inc., two of Health Dialog's partners in the Medicare Health Support project.

For example, Health Dialog might provide a face-to-face visit for a Medicare beneficiary upon discharge from a hospital, Hall says. The goal of the visit is to get the patient "back on the road to self-reliance. We try to touch as many transition points as possible with face-to-face visits." Health Dialog also works to identify the patient's "health partner" — a family member, neighbor, roommate or facility staffer who serves as a representative for health care decision making — to provide health coaching or other education to that person.

Stone says he doesn't expect Medicare DM programs to provide a boost to in-home DM services, however. He says the greatest challenge in serving Medicare beneficiaries is not coordinating in-person visits, but identifying the patient's primary care physician.

DM firms face a particular challenge in providing DM services to patients in nursing homes.

"Nursing-home patients are a whole different ball of wax," Stone says. "And of course, that's a population that we both as an individual company and as an industry do not encounter in the commercial market."

"You can't reach nursing-home patients on the phone," Lewis explains. "So several [DM firms] have contracted with physician rounding companies like a Matrix Medical [Network, which provides care to patients in long-term care settings]," he says. "A DM vendor is nuts if they think they can manage a nursing-home patient on the phone."

One issue is that "when somebody's under the direct care of a facility, the health-coaching support is to the facility and health partner," Hall says. "And if somebody does not have the capability or the cognitive ability to act on their own behalf, the facility and health partner become a critical component for motivation and confidence," she contends.

Health Dialog then works with the health partner to help that person "understand what they can and can't control," Hall says, "even if it is just reminders for quality measures — things like flu shots," or helping to support the preparation of advance directives.

If the patient's stay in a nursing facility is only temporary, Health Dialog provides health coaching to help patients prepare to be independent again. "Oftentimes, a hiccup occurs when someone goes home, if they haven't been brought back up to self-dependency," Hall says.

American Healthways employs a handful of nurses in the Washington, D.C., and Maryland areas, where it is operating a Medicare Health Support pilot, Stone says. "We are going to be evaluating as part of the whole process whether that is an effective way" of serving this population, he says.

He estimates that in the Medicare population, 4% to 8% of beneficiaries permanently reside in a nursing home. "We're sending nurses in there to speak to them and their caregivers about participation and get them engaged in the program."

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