In some ways, CMS in general, and Medicare in particular, have been major supporters of disease management (DM), sponsoring a large number of demonstration projects involving large numbers of DM providers and large populations of beneficiaries. They have thus gained the ability to learn more about the narrow application of DM to insured populations, narrowed still further by being Medicare beneficiaries, who tend to be seniors and to be far more likely to have multiple chronic conditions, as well as to have had them longer than is the case with employee populations.

Medicare’s limited focus is fully understandable if it sees itself as only a payer for seniors’ chronic-disease-caused medical, hospital and pharmaceutical expenses. As an arm of the federal government, however, it might also see itself, at least partly, as the source of information and insights that can guide improvements in DM, in general, and its use by DM providers, and payment by other payers, including commercial insurers and employers, as well as for consumers, who have much to gain from the best DM practices and providers.

In this latter role, CMS has failed utterly. For one thing, it has defined its role as that of determining whether or not DM works, as a generic method for a single purpose, namely saving the government money. As noted in a recent analysis of CMS’s decision in its Medicare Health Support (MHS) demonstration, the only reports on this program issued by CMS have simply mentioned that it failed to achieve the financial goals set for the program. [“MHS in Jeopardy: Part 1” Health Leaders Media Audio Feature Feb 20, 2008]

While this program has been running for 2-1/2 years, the only information that CMS has shared was that in a lengthy preliminary report on six months’ experience, which indicated that financial results at that point had not met CMS expectations. This was an overall conclusion, however, and based on the financial results alone, rather than reflecting quality of care and patient satisfaction improvements, that were supposed to also be included in its criteria for success. When CMS recently announced that the entire project will be terminated after “Phase 1”, with no “Phase 2” envisioned, it supplied no additional data on achievements in the most recent two years, nor about anything about the specific performance dimensions not achieved, merely that : “…Phase 1 of the program is not meeting statutory requirements.” [“Fact Sheet: Completion of Phase I of Medicare Health Support Program” Medicare/CMS]

It did include the statement that: “The CMS will determine whether to expand the pilot into Phase II if the results of the independent evaluation indicate that any {emphasis mine} of the programs (or program components) meet the conditions for expansion as specified in statute.” In other words, apparently neither CMS nor anyone else knows yet whether any of the individual DM programs and providers in the project succeeded, in which if any of the success dimensions, nor is there any information on what any of them achieved in the two years since the initial report came out. But CMS ended the project, nevertheless.

Considering the September announcement by the CMS Acting Administrator Kevin Weems promising a higher level of transparency and accountability at his agency, this is hardly an example of either from most observers’ perspective. [J. Young “New Medicare Chief Promises Accountability” TheHill.com Sep 12, 2007)] 68,000 beneficiaries will lose their support between July and December, with no explanation other than the terse “not meeting statutory requirements” comment, an no data backing up the comment at all, other than the first six months’ report.

On balance, i.e. over all eight MHS provider organizations, the six-month report was not positive, as far as financial savings were concerned. While savings were achieved, in terms of lower monthly costs for program participants vs. non-participant controls, when the management fee charged by the providers were included, none of them had achieved the 5% savings minimum set by CMS. In fact, two of them ended up adding to the total costs that Medicare had to pay for participants.

On the other hand, six of the eight had achieved net savings after their management fees were counted. One, in fact, saved a net 4%, though only two others achieved over 1%, namely 1.1% and 1.5%, while the others achieved only a fraction of 1%. This may be the “statutory requirement” that caused the negative decision about Phase I, though without data on the subsequent two years, it is impossible to tell whether similar results were achieved in the longer period. [N. McCall, et al. “Evaluation of Phase I of Medicare Health Support (Formerly Voluntary Chronic Care Improvement) Pilot Program Under Traditional Fee-for-Service Medicare” CMS/Medicare]

The MHS example is but one in a series of federal reports that have concluded that DM doesn’t work, where all have treated DM as if it were a single intervention form, rather than the widely varying forms that are, in reality, used by different suppliers thereof. There are far more than eight DM providers involved in the study, so the results only apply to their results, not to what others have achieved, or even what these same providers have achieved with other populations, payers, and requirements.

As one of the people speaking in the Health Leaders Media audio feature cited above argued, this is tantamount to the federal government testing a selection of eight drugs used for different patients and conditions, and making an overall judgment about the efficacy of all drugs used for all patients for all conditions. It is an absurd attempt on the face, and one that fails utterly to fulfill government’s role as a source of information that can help anyone.

If CMS had cited the data that caused them to reach their negative conclusion, and it showed that none of the eight providers involved had achieved any of the desired results, that would be one thing, but even then limited to these eight and this unique situation. Yet it adds to the already significant number of previous reports that condemn DM without mentioning the cases where it has worked even for CMS, among the different participants in its demonstrations.

Whether CMS has chosen to be an enemy of DM and its providers is unclear, but it is certainly behaving and reporting in a way that damages the hopes of chronic disease patients and DM providers, while apparently learning nothing useful in the process, for themselves, patients or providers. Shame on CMS!