While everybody acknowledges physician buy-in is essential for a successful disease management (DM) program, there is growing evidence physicians often are not buying in - sometimes for logical and compelling reasons and sometimes simply in protest of how they believe they're treated.

     Until those feelings as well as the concrete situations physicians cite are addressed, DM industry observers acknowledge, DM program results are likely to be far less than optimal.

     Specific comments by physicians and others reflecting this situation appeared this month and last on Disease Management Forum, a popular e-mail discussion group for DM professionals sponsored by Managed Care magazine. DMN contacted some of the e-mail discussants and obtained permission to use their comments in this article.

     "Many of these so-called `programs' are more exercises in attempting to get the physician to cooperate in a contract made by the provider and not scientifically based," says G. Tom Surber, M.D., a family practitioner and occupational medicine physician at a multi-specialty clinic in Norfolk, Neb., in the e-mail forum. Surber cites as an example being "harassed' by a "national pharmacy evaluation program" to use certain brands of albuterol. "They list only the brands as acceptable that they have a financially advantageous contract [for], and tell me that other albuterol generics are not acceptable and that it is my responsibility to prescribe their brand choice."

     Moreover, asserts Surber, "many of these `programs' are contradictory." He cites being told by one insurer to start with Bactrim generics for otitis media while another insists that he start with Amoxicillin generics. "Without a real scientific basis, and with contradictory `programs,' who are we to believe?" he asks. He adds that "now, some literature is insisting that we not use any antibiotics for otitis media."

     Other problems mentioned by Surber include huge numbers of differing recommendations for primary care. "I am getting lists of tests that each HMO expects to have done for their patients," he says, for instance. "These all vary considerably in content and format."

     Surber is sympathetic to the objectives of DM. "I agree that the chronic diseases, such as diabetes, CHF and other cardiac diseases, hyperlipidemia, arthritis should be managed by some sort of planned program," he says. "Yet, the allowed tests under Medicare for hyperlipidemia alone have changed at least twice in 1998. These programs are shipped to us buried deep in long lists and pages of numbers, incomprehensible to doctors, with rudely diagrammed patterns to follow."

     Says Surber, "At least send us the tools and data we are expected to use clinically in a useful format and structured so that we do not have to rely on coders and others who deal with those pages-long number lists to ferret out the clinically useful data."

     Surber's comments clearly resonated with some of the other physicians on the e-mail forum.

     "When we look at practice parameters/clinical guidelines developed by specialty societies which try to be evidence based but often are consensus based, we know that 95% is crap," according to another e-mail discussant, Steve Rodgers, M.D., whose Wilmington, Del. practice centers on disability evaluations. With a heavy dose of sarcasm and irony, Rodgers continues, "With managed care and DM, if the goal is the bottom line, the goal is possibly being met and, even if it isn't, a lot of people are fully employed." He also says, "If the goal is scientific, logical, internally consistent, evidence-based, statistically valid, epidemiologically sound health care, then 99.9% is crap."

     Says David Kibbe, M.D., CEO of Future HealthCare, Inc. in Chapel Hill, N.C.: "Most DM programs are a form of disintermediation in which the `middleman' being cut out is the physician."

     Other physicians in the forum have attempted to explain the foundation of their colleagues' feelings.

     "Physician champions, aligned financial incentives, and physician participation in guideline development . . . are all likely to pull for a greater degree of provider participation in the new health-care paradigm," says Mark Vanelli, M.D., a consultant and instructor in psychiatry at Harvard Medical School in Massachusetts. "Such actions, however, do not address the underlying sense of betrayal and anger that afflicts many health-care providers today. And it is these factors, when unaddressed, that more routinely defeat attempts to promote change."

     Even physicians who are executives of DM firms expressed both understanding and some degree of agreement with their colleagues on the e-mail forum.

     "I agree the buy-in will be one physician at a time," says Renaissance Health Care, Inc. Chief Medical Officer Coleman Mosley, M.D. in San Diego. "But the set of arguments used will be limited, and each person will find the ones that fit their own needs - including the choice of not buying in."

     Nephrologist Mosley, though, is more optimistic about the potential outcome. "Disease management plans," he says, "will hopefully be an evolutionary step in medicine, not to replace managed care but to find the niche where the faults of managed care in regards to the chronically ill, not the episodically ill, can be corrected. Physician/patient/- health plan buy-in will occur when we in this process can show mutual benefits."

     Those benefits may need to include extra compensation, says Warren Todd, business development head at consultant Hastings Healthcare Group, whose clients include pharmaceutical firms active in DM.

     But the key to dealing with the "very visceral" reaction to DM evidenced by the physician comments on the e-mail forum may be understanding what has led the physicians to this point, suggests consultant Vince Kuraitis, a principal in Better Health Technologies, LLC (Boise, Ida.) and a participant in the forum.

     A lot of DM vendors "have alienated" physicians, Kuraitis says in an interview with DMN, by taking competitive positions versus the doctors. He cites as an example the initial carve-out DM models, which by in effect threatening the physicians with being cut out of their patients' future care, "angered them greatly." While most major vendors now are moving toward carve-in models that don't have this problem, there are still other factors contributing to extreme reactions, he says.

     "Docs are beleaguered," says Kuraitis, and it is hard to get their attention focused on DM compared with many other pressing things. Moreover, "there's [only] lip service being given to this notion of truly putting the doctors up front in DM planning and implementation," he charges. Referring to DM vendors, he adds, "Nobody's really got this down yet."

     Kuraitis, however, also is quick to say the current situation should not be interpreted as simply a failure of DM companies. The mindset DM vendors need in order to be successful in getting physician buy-in, he says, is "evolving." More vendors are realizing they need to target up front the "moment of truth" in medical decision-making that occurs between the doctor and patient "behind closed doors." To do this, the companies must come in with a model that aims to make DM successful in all ways for the physician, he explains.

     Specifically, he says, there needs to be "one-on-one" interaction with physician leaders and other physicians before a DM program begins, something he acknowledges is tough when the program is on a tight time frame.

     And the vendors may need models with more economic incentives, such as joint ventures or giving physicians equity, Kuraitis says, although he notes this must be done carefully to avoid legal problems.

     In response to the fears several physicians on the e-mail forum expressed that DM programs make them a "middleman" to be "disintermediated" or cut out of a major role, Kuraitis says "it's pretty tough to `disintermediate' someone controlling 80% of your costs."