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FROM CARE MANAGEMENTFROM CARE MANAGEMENTTO MANAGED CARETO MANAGED CARE
Professor Samir MossaConsultant Family Med., Pediatric &
Medical Education.
Director of Academic and Research Affairs
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The changing role of theThe changing role of thepharmaceutical industry;pharmaceutical industry;
From manufacturer of
pharmaceuticals to partner inhealth care.
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Presentation OverviewPresentation Overview
Background and history
Strategies for the future
Definition of
A) Disease ManagementB) Managed Care
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Background and historyBackground and history
Forces forchange
Forces forchange
RethinkingStrategy
RethinkingStrategy
NewCapabilities
NewCapabilities
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The State1. Demographics (more elderly people)
2. Health care costs continue to rise above inflation
3. Political reforms to control costs4. Formularies / prescription control / price control
5. Prioritization of health care service offered
6. Debating alternatives to existing structure7. New treatments / technologies (biotechnology)
8. Information technology
Forces to ChangeForces to Change Background and history..Background and history..
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The pharmaceutical industry.1. Rising costs of Research and Development
2. Generic competition (patents)
3. Parallel import4. Reimbursement / price control
5. Lower margins
6. New costumer constellations7. Changing customer expectations (patients)
8. Information technology
Forces to ChangeForces to Change Background and history..
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Strategies for the futureStrategies for the future
Forces forchange
Forces forchange
Rethinkingstrategy
Rethinkingstrategy
Newcapabilities
Newcapabilities
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Rethinking strategyRethinking strategy
The pharmaceutical industry faces
A number of strategic options.
Unique value added
pharmaceuticals (Innovation)
Distribution, channel blockcompetition (vertical integration)
Combine Rx, Gx, OTC, acquire or
merge critical mass, Disease man.Approaches (horizontal integration)
. Which may be adopted in combination
Globalization
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The traditional health value chainThe traditional health value chainThe traditional health value chain
Rethinking strategyRethinking strategy
Pharmaceuticalcompany
Provider
Purchaser
Patient
Sales and
Marketing
DistributionManufact.R&D
Follow-upTreatmentDiagnosisScreening
AuditContractingActivityRequirement
Needs
Assess.
Recovery orChronicman.
interventionSymptomsPre-
Symptoms
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The traditional health value chain isThe traditional health value chain is
beingbeing turnedturned upside down asupside down ascustomers and needs evolvecustomers and needs evolve
Rethinking strategy
Patient Serv ic e andin te rvent ion
In fo rmat ion Value
con t rac t
Agreed
hea lt h care goals
Purchaser ( Ka izen)
Improvequa l i t y
Purchase
ou t comes
Set
S t ra tegy
Aggregate
Populat ionneeds
Provider Improve cos t e f fec t i veness
Audi t Ef fect in te rvent ion
Setou t comes
Pharmacycompany
Improve
so lu t ions
Del iver
so lu t ions
Develop
so lu t ions
Assess
ou t come
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Disease Management and Manage CareDisease Management and Manage Care
Forces for changeForces for change
Rethinkingstrategy
Rethinkingstrategy
Newcapabilities
Newcapabilities
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New Capabilities Diseases Management and ManageCare
What is Diseases Managem ent ?
An integrated system of customized
Interventions, measurements, andrefinements to current processes of
care designed to optimize clinicaland economic outcomes within a
specific disease state.
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New capabilitiesNew capabilities
Disease Management and Managed
Care
What is Managed Care?
A process to maximize the health gain of a
community within limited resources, byensuring that an appropriate range and level of
services are provided, and by monitoring on a
case-by-case basis to ensure that they arecontinuously improved to meet national
targets for health and individual health needs
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New capabilitiesNew capabilities Disease management andManage Care
Manage Care cannot be owned, it must be
developed through partnership
purchaser/ provider
primary/ secondary/ community/ pharmacist hospital/ wholesaler/ supplier
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New capabilitiesNew capabilities Disease Management andManage Care
Support for patient groups to support treatment options
Development of outcomes data bases with commercial supportHealth Provider assisted to produce best practice guidelinesCommercial support for changes to clinical practice
Joint venture to redesign health processesUse of patient outcome and response measuresCollaboration to build health information systems
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New capabilitiesNew capabilitiesNew capabilitiesDisease Management andDisease Management and
Managed CareManaged Care
YesterdayDevelopment and marketing
based on products
TomorrowDevelopment and marketing
based on customers needs
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New capabilitiesNew capabilities Disease Management andDisease Management andManage careManage care
Considerable Barriers exist..
Lack of information and/or access to it
Professional skepticism in the health care sector
Un-conceived management
Risk aversiveness
New entries ( IT companies )
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New capabilitiesNew capabilities Disease ManagementDisease Management
and Managed Careand Managed Care....
The risk of NOT pursuing Managed
Care/Disease Management.
Loss of access to key customer/decisions
makers
Loss of access to information
Loss of access to innovation
Loss of access to opportunities & potential
rewards
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Patient
IndustryPayer
Provider
QOL Co-Payment Knowledge
Value of drugCustomer Focus
Cost Quality PR
Easier decision making
Efficiency
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NowNow
PharmaSurgical
7%7 + %
Direct
CostsCosts
Indirect
Future ?Future ?
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Before the 90-ties The 90-ties
Pharmacy
65% Hospital1%
PhysicianPhysician
3%3%
PsychiatricPsychiatricHospitalHospital
6%6%
PsychiatristPsychiatristPsychiatristPsychiatrist
24%24%
PsychiatricPsychiatric
HospitalHospital21%21%Physician
Physician
7%7%
Hospital27%
Pharmacy
21%
Depression-Related Direct Costs
TCA Mean Cost/Patient - $ 960
Depression-Related Direct Costs
SSRI Mean Cost/Patient - $508Source: Sciar DA ,et al. Antidepressant Pharmacotherapy: Economic
Outcomes in a Health Maintenance Organization ,Clinical Therapeutics, 1994;16:715-730
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A continuous process to optimize care outcomes
An integrated system of medical and paramedicalintervention, with continuous measurements and consequentrefinements, design to optimize clinical and economic out comeswithin a specific disease state.
DISEASE MANAGEMENT
MANAGED CARE
An Integrated System for Financing and
Delivering Health Care Services
(Integrating of prayer and provider)
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Disease ManagementDisease Management ....1 specific disease (diabetes, depression, asthma, etc.)1 specific disease (diabetes, depression, asthma, etc.)
Measurements
Clinical and/or
Economical and/or
Quality of Life
with the purpose to optimize a specific treatment
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Difference between diseaseDifference between disease
management and managed caremanagement and managed care
Dimensions:Dimensions:
Quality of care
Equity of funding Equity of access
Cost of care
Evidence based purchasing versus evidence based medicine?Source: Mercer report on Disease Management
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Searching for the Care OptimumSearching for the Care Optimum
Suboptimal Care: Too Little or too much !!
Ideal
Disease Management
Objective
QOL
Rationalizing
Rationing
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The disease Management WheelThe disease Management WheelPrevention and Screening
Objectives forImprovement
Diagnoses
Communicate
Intervention andTreatment
Monitor
Follow-up Guidelines
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The Process of Disease Management: action stepsThe Process of Disease Management: action steps
Situation
Analysis
Situation
Analysis
Delivery AuditDelivery Audit
Problem/opportunity
Identification
Problem/opportunity
Identification
OptionEvaluationOptionEvaluation
Action PlanAction Plan
ImplementationImplementation
Monitor & ReviewMonitor & Review
Healthcare market development
Population demands / influences
Current practice
Review / baseline outcomes
Meeting healthcare requirement
Financial Targets
Disease Management tools
Assessing potential impact
Actions to meet objectives
Measures & Milestone
Buy In at organizational level
Change management
Achievable measures
Feedback loops
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Disease Management Tools
The Disease MapUnderstanding the diseaseIdentifying problems and opportunitiesTailoring solutionsMeasuring outcomes
Patient Management ProgramsSelf help programmersEducations programmers
Healthcare Planning DatabasePlanning efficient healthcare facilitiesStudying variations in disease episodesAnalyzing referral patterns
Professional Education PackagesInfluencing behaviorEnsuring best practice
Re-organizing delivery of healthcare services
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What are we trying to do
and how are we trying to position ourselves?
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Emphasis shift:Emphasis shift:
new productnew product--market combinationsmarket combinationsTraditional Emerging
Costumers
Drugs
Doctors DoctorsPharmacist PharmacistGovernment Hospitals
Government
Private Insurance
Purchasers/consortia
Patients
For profit HC providers
Safety Safety-Efficacy
Efficacy Cost effectiveness
Outcomes
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Primary Disease Management ModelsPrimary Disease Management Models
Market and manageUtilization of
packages of
drugs used to treat
populations Drug Manager
Discover, develop,and market drugs
and offer selected
value-added
services that
enhance drug sales
Drug Supplier
Care Manager
Manage delivery of
services to a definedpatient population
ServiceProvider
Develop and sell a
variety of servicesto facilitate thedisease
management
process
Drug Supplier
Drug Supplier
Care Manager
ServiceProvider
Minor Significant
Involvement in Care Management & Delivery
Services
only
Drugs
only
F
ocus
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Characteristics of Disease Management
Addresses process of healthcare delivery Addresses structure of healthcare delivery
Hollistic not component focus
Success based on improving outcomes
Best practice and evidence
Payment based on benefits delivered
Partnerships
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Integrated Diabetes Management ExampleIntegrated Diabetes Management Example
PilotIncentiveProgram
Develop and get Buy in for
Incentive Program
Guideline
Development
FacilitateTeam
Decisions
Support Systems
Development
Process &OutcomeMeasures
GuidelineImplementation
Outcome
based
behavior( HbA1c )
Interventions
for:
Plan
Providers
Patients
Reimbursement: LOS Total costs/Survey HbAtc
OutpatientEducationProgram
Case Management
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Control Diabetes ServicesControl Diabetes ServicesPotential to Reduce Total Health Care CostsPotential to Reduce Total Health Care Costs
$ 10,000
$ 9,000
$ 8,000
$ 7,000
$ 6,000
$ 5,000
$ 4,000
$ 3,000
$ 2,000
$ 1,000
$ 0
Status Quo Control Intervention
Other
Homehealth
Drugs &DME
Office Visit
Outpatient
Inpatient *
( 25%
reduction )
Self mgmttraining
Diabetes Outpatient Education Program Demonstrating Reduced Hospitalization and cost savings, Centers, for DiseaseControl ( Summary of literaure : Diabetes Education reduced hospitalizations by 20 to 72%
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Disease Management: a logical next stepDisease Management: a logical next step
Medication
Management
Disease
Management
Drug
Interactions:Lower Cost
Therapy change
Acute to
MaintenanceDosage
Promote Patient
Compliance/Education
Conduct Intensive
Intervention topromote Most
Appropriate Diagnosis
and Treatment of
Patient
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Disease Management : Selection CriteriaDisease Management : Selection Criteria
Selection Criteria
Clear and unambiguous category High variability in treatmentpatterns and outcomes.
High per patient costs Low frequency of co-morbidity
Unrealised opportunities for near-
term cost savings and improvedoutcomes
Specialised expertise and/or data
needed to manage effectively
Likely DiseaseTargets
Diabetes
AsthmaMental Health
Cancer
Haemophilia
EpilepsyLow Back Pain
Post-Traumatic
Rehabilitation
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Key success factorsKey success factors
Commitment
Credibility
Culture
Data
Success
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Additional competences required forAdditional competences required for
Disease ManagementDisease Management
Risk analysis and actuarial skills ( Insurance )
Clinical decision making ( Medical Profession )
Care Management ( Hospital and Nurses )
Business Management
Information Technology
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Disease ManagementDisease Management People latch on to these buzzwordsbuzzwords and
start to equate them with something thatsmore concrete or tangible, like clinical
guidelines, product inserts, or patient
education.
Then they say theyre doing disease
management and thats a bunch of bull .
James Couch, M.D.
Johns Hopkins University