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Role of insurance cos in US and pharma cos in India

Anil Nayak
Wednesday, March 13, 2013, 08:00 Hrs  [IST]

Patient adherence is the next big frontier in the healthcare sector. Lack of patient adherence to prescribed medications poses a tremendous challenge to the global healthcare community. The vast majority of pharmaceutical, pharmacy and payer executives explain low adherence levels by pointing to patient-related factors, such as poor knowledge of the disease, inadequate perceptions of the need for treatment and forgetfulness.

Diseases and health problems
There are many diseases and health problems that people deal with every day. Dealing with a chronic disease can be much harder. A portion of your time is always used in treating the disease or going to the doctor. Healthcare industry in India is providing organised cure but was lacking organised care. There is continuous gap in chronic care and lifestyle conditions awareness, screening and behavioural modification. In order to control over the chronic diseases, this concept of remotely managed disease management/patient management, this is certainly picking up in India. This is because access to information and disease awareness is very low and healthcare cost rising. A chronic disease is an illness that is persistent or long lasting and also recurrent it is controllable but, in many cases can't be cured. They include diseases such as HIV, arthritis, diabetes, cancer, cardio vascular, hepatitis B and respiratory disease, and are among the most costly and common of all health conditions around the world. Chronic disease is a leading cause of increasing health care costs. More than half of all population of the world has at least one chronic condition. Disease management is a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. It may reduce healthcare costs or improve quality of life for individuals by preventing or minimizing the effects of disease.

In the United States, disease management is a large industry with many vendors. Major disease management organizations based on revenues and other criteria. Disease management is of particular importance to health plans, agencies, trusts, associations and employers that offer health insurance. Currently deployment initiatives are dominated by health insurance companies and the government.

However disease management while highly philanthropic in its appearance has posed a challenge for private insurance companies. It is found in the US that a person changes a health insurance company every two and a half  years.

The dilemma faced by health insurance company is that it would be investing in the better health of an individual who would move to a different insurer in two years and it would be this new insurance company enjoying the economic benefits.

Health insurers are slowly and steadily noticing the overall good in the concept of disease management as it has proved to be a great sign for the industry.

Disease management programmes can benefit the patient, employer and health insurance carrier. The goal for the patient is management and understanding of his condition and ensuring he regularly visits his primary-care physician. The goal for the employer is to improve productivity of employees with conditions who miss work due to their condition or their child's condition. For the health insurer, a healthier patient reduces the cost of care. This also benefits the employer by offering lower health care premiums, which ultimately pass through to the patient/employee as well. After identifying a patient with a chronic condition, a clinical care manager attempts to speak with her to assess her condition. This assessment traditionally occurs by telephone but may occur face-to-face. The assessment is a series of questions about the patient's current condition, lifestyle and behavioural actions to determine his/her risk level. Based on the assessment answers, the care manager develops, in conjunction with the patient, a care plan for the patient to follow. The care manager from disease management and patient will have ongoing meetings with frequency determined by risk level the more high-risk the patient, the more frequent the discussions. At these sessions, the goal is to educate the patient and improve his health and lifestyle.

Non adherence to medication
Non adherence to medication is a major impact for poor therapy outcomes and treatment for chronic disease. Globally pharmaceutical companies lose approximately US$ 30 billion per year due to non adherence.

The pharmaceutical industry is gearing up to the idea of disease management since for them it is recovering lost revenue. With tremendous medical non-compliance the pharmaceutical company is losing revenue, since the patient does not fill/re-fill his/her prescription. With improvement in compliance they expect their revenues to increase.

Pharmaceutical companies are aggressively marketing disease management programmes mostly through outsourcing to third party disease management service providers.

So, the year 2013 will see a transformed and deployed new models in disease management. The landscape is changing for commercial populations within health plans and, specifically, for disease management efforts within health plans. To remain relevant and competitive, health plans should consider evolving their disease management programmes, adopting a more holistic approach with robust value propositions, insurers needs to make disease management an integral part of their health plan offering as this would significantly reduce claims due to positive outcomes of therapy due to disease management interventions and lesser hospitalization. As regulatory changes, reforms and economic forces alter the demands and expectations for health plans, they should consider embracing new trends and remain adaptable to innovations. All of this requires flexibility in both business processes and technology and thoughtful, proactive decision-making to be leading the charge rather than falling behind. To achieve efficacy, the disease management sector is leveraging on its technical power to make disease management more effective and efficient and to take it next level with its innovative technology.

In addition to that, it will see a huge change in the process of rolling out day care centre’s and family doctor services to address the needs of primary health care in major cities of India by this year end and thus the sector will witness a pioneer in home based patient care management which would be driven by annual subscriptions with consumers as payer.

(The author is cofounder, Kartavya Healtheon, Mumbai)


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