Summary
The apparent abandonment of American Healthways DM by CMS is a big deal. DM is one of the very few promising techniques available to curve costs, and yes, even improve wellness by preventing onset of disease attack. The premise of limiting "admissions" is what population based management began on. It has blossomed into real real prevention. Quantifying the admissions that did not happen is "subjective-soup". Inherently, the management of senior diabetes to prevent coma, renal failure,stroke and MI saves big bucks. Inherently, managing child asthma, prenatal, neonatal, bariatrics medicine, hypertension are very good ideas. Prepaid population based medicine v. competing fee for service medicine at least has something to incent (pay) doctors to manage health and not just provide procedures AFTER disease onset. We tried to get AH to buy reinsurance for their "fees at risk" program several times without success. For their sake, we hope they bought it from someone.
Analysis
Much of CMS disbelief is the problem of the DM industry setting, and then changing the original evaluation criteria. One leading Guru admitted their evaluation criteria as wrong, and apparently attempted to change it affect more accurate experience/savings. Whatever they did, it did not convince OIG or CMS.
One major problem running these programs is quantifying how much money was saved for catastrophic care that never happened. For example, a 72 year old diabetic patient mishandles their diabetes and goes into a coma & ICU for 90 days at $500,000 billed charges. The cost for DM is under a few dollars per member per month.... Another contentious issue is quantifying costs of absent or under performing (sick) employees - a concept known as presenteeism. The savings are huge if you buy the presenteeism concept which is real.
There is little question that managing expensive chronic conditions is good idea. Regrettably, altruistic medical capitalism under Fee For Service provides little compensation for managing the larger patient lifestyle practices that threaten good health.
