Abstract

The articles by Ellrodt et al. and Smith et al. in the recent edition of Hospital Quarterly (Vol. 2, No.1) provided an excellent overview of disease management and its potential introduction to Canada. However, both articles minimized the fact that disease-state management is nothing more than a subset of managed care. Managed care is first and foremost about cost containment. While it is convenient for healthcare administrators to focus discussion on improved patient outcomes and improved quality, the underlying premise is cost containment and the economic dilemma of allocating limited resources in the face of unlimited demand. If managed care was strictly about quality and patient satisfaction it would have been introduced many years ago when money was plentiful.

As a subset of managed care, disease management can be defined as the active case management of targeted patients having specific chronic diseases, and who are at risk for a high utilization of healthcare services. The goal of disease management is to have providers and patients improve outcomes of quality and satisfaction, while reducing costs. The techniques to achieve this include patient education, follow-up treatment adjustments, and compliance monitoring. A disease management or managed care approach to healthcare will require substantial changes to our existing healthcare-delivery system and would involve significant compromises between stakeholders.

Governments, being the largest payers for healthcare services, have a tremendous amount to gain from managed care - especially cost containment. The difficulty in managed care, for government, is its structured framework when compared to the existing system. Politically, the government is vulnerable when suggesting changes such as those required by managed care. After all, managed care is viewed as all that is wrong with the American healthcare system including cost containment, poor patient care, risk selection and capitation. Governments may also have to trust physicians, hospitals and other payers such as employers to a greater extent and will have to give up the over-riding role they currently have - a very difficult thing for ministries of health to do. For managed care to work, devolution of authority and power must occur.

At present, physicians, chiropractors, psychologists, dentists, rehabilitation agencies, pharmacies, and other healthcare vendors are third-party providers of services and have minimal accountability to the payer for the quality and cost of services provided to patients. Physicians and healthcare providers tend to regard managed care as a method of reducing their incomes, increasing their workloads, decreasing their autonomy and interfering with the patient-physician relationship. In a managed care environment these vendors and providers will be subject to utilization review, quality assurance processes, standardization of care, outcome measurement, performance review, and possibly to alternative systems of payment such as capitation or blended payment systems. They are likely to resist this type of change, for providers - like patients - have enjoyed a relatively autonomous existence within the healthcare system.

Consumers and patients may have the most to lose, for they enjoy the freedom of choice, reasonable access, unlimited autonomy and little, if any, accountability. For consumers, managed care means limiting their current privileges, for even today, under constrained access, those that are seriously or chronically ill do get the care they need, even though it may not be in the most efficient or coordinated manner. Patients' gains under managed care, may be even fewer if, because of our single-payer integrated-health system, competition does not evolve.

The concept of managed care has, to date, remained an anathema to the Canadian healthcare system. In fact, even the use of the term, managed care, within Canada raises the ire of patients, physicians, governments and health administrators.

Managed care can be abusive, for its principles lie in cost containment. With capitation as the preferred funding model of managed care, the potential for poor patient care, adverse risk selection ("cream skimming"), and mediocre provider competency is probable. However, the positive features of managed care, such as evidence-based activities, consumer cost sharing and accountability, best practices, a focus on prevention, utilization review and provider profiling, are often overlooked.

If, in Canada, we move to a managed care system of health delivery, Canadians must accept both the benefits and the consequences of moving to such a system. The reality is that before managed care or disease management can be implemented and function close to its ideological design, a complete restructuring of the healthcare system is required.

About the Author

Arif Bhimji, MD,
Vice President
Magna International
Aurora, ON