From all indications, the role of provider organizations in both developing and implementing disease management (DM) programs will grow substantially in 1999. That's the unanimous view of experts in health plans, DM vendors, and providers themselves queried by DMN at the end of 1998.

     Part of the trend, they say, results simply from "following the risk." Increasingly, it is provider organizations that are bearing risk in managed care arrangements, and they are having to beef up medical management capabilities to handle that. While some major and successful managed care organizations (MCOs) - notably Humana Inc. - still operate largely centralized DM programs, a growing number of MCOs puts much of the DM initiation authority in their major providers.

     This is the case, for instance, with Tufts Health Plan, which has about a million members in Massachusetts, Rhode Island, and Maine and has been operating its own DM programs for 2 1/2 to three years. Although Peter DiBiaso, Tufts' manager, disease state programs, acknowledges that integrated delivery systems (IDSs) generally don't yet have all the capabilities needed for DM, they are "moving in that direction."

     The biggest thing the IDSs lack, according to DiBiaso, is "data collection" know-how - specifically the "ability to completely track outcomes." Helping to offset this, however, is the importance of "getting true provider champions" for DM programs, he says.

     Moreover, in the New England area served by the Tufts plan, IDSs increasingly are becoming major bearers of risk, he notes. DiBiaso says their moves into DM mark a "logical progression" from these trends and, as a result, "in 1999, we'll be doing more collaboration with IDSs" in DM programs.

     "We're trying to find a balance between what we can do," he says, and what big IDSs such as Partners and CareGroup in the Boston area can supply in DM. About 55% of Tufts' members are associated with IDSs, DiBiaso points out. Therefore, he adds, Tufts already has worked with the two big Boston-area IDSs and others on DM and will be "very provider-focused" this year.

     Provider activity in developing and implementing DM programs "will accelerate dramatically" in 1999, concurs Scott Weingarten, M.D., director of health services research for Cedars-Sinai Health System in Los Angeles. He attributes this to the fact that "patient care is their business" and to the rising number of "success stories" of providers in DM, which in turn leads other providers to get involved. One of those "success stories" is the hypertension DM program of Cedars-Sinai itself.

     Some provider organizations are "fairly sophisticated," Weingarten says, and will be able to do DM on their own. Those smaller and less DM-experienced providers can get outside assistance primarily from consulting firms, and some will partner with pharmaceutical producers, he says. But he adds that only those drug firms offering "real value" and expertise will land such partnerships.

     Pharmaceutical companies will be offering these partnerships more than in the past because they recognize providers increasingly are taking risk in capitated contracts, he says.

     But Weingarten does not expect provider organizations otherwise to have more money available for DM programs than in prior years. They still will be "financially challenged," he says, but the providers will figure out how to do DM "better and cheaper" as they gain experience with it.

     The growing provider role also will pertain to provider groups within MCOs. Even staff-model HMOs need to "incentivize" physicians to help usage of DM programs, says Maggie Gunter, Ph.D., vice president and executive director of the Lovelace Clinic Foundation. That Albuquerque, N.M.-based organization is affiliated with Lovelace Health Systems, which has both staff- and network-model HMOs.

     Gunter explains that the idea of placing risk with the person closest to the patient still is important, including in DM. Providers need to reap some of the fruits of DM program successes if MCOs want their active participation, especially since DM takes up physician time, she asserts.

     Robin Johnson, director of population-based services at Group Health Cooperative of Puget Sound, which has both group- and network-model operations, notes that her MCO incentivizes even its group-model providers for DM. The incentives, she says, are to participate in clinical improvement services the MCO wants to encourage, such as retinal eye screenings for diabetics and lipid measurements.

     The whole reimbursement system is moving toward encouraging providers to do what they "intuitively" realized "for years" they should do but never before had the financial incentive to do, says Los Angeles-based consultant Bettina Kurowski, Ph.D.

     But the increased provider/IDS activity in DM will not necessarily be in vendor programs, cautions Kurowski, who formerly was senior vice president of DM vendor Salick Health Care. She predicts that pharmaceutical producers, for instance, "will continue to have difficulties" with providers in DM unless they offer the providers a "smorgasbord of services" to choose from or if they "fill regulatory needs."

     Providers still are wary of drug manufacturers, she says, which they regard as just looking for new ways to sell pharmaceuticals. Although this is true in many cases, according to Kurowski, the providers don't yet realize that in some diseases - such as asthma - they can achieve strong DM results through improved compliance using drug-maker programs such as that of Schering-Plough's Integrated Therapeutics Group.

     Kurowski maintains, however, that there are other diseases for which more pharmaceuticals don't yield better results, especially since compliance is not a major issue in outcomes, and that providers need to make this distinction.