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Chairman, Government Affairs Committee,

Disease Management Association of America
Vice President, McKesson Health Solutions I am pleased to submit this statement on behalf of the Disease Management Association of American (DMAA) and McKesson to the House Veterans' Affairs Health Subcommittee. My name is Dr. Sandeep Wadhwa, and I am the Chairman of the Government Affairs Committee of the DMAA. I also oversee disease management programs for McKesson Corporation, the 15th largest company in the US and the nation’s largest healthcare services company. McKesson is one of largest providers of disease management (DM) services to government health payers including Medicaid, Medicare, FEHBP, TriCare and the VA. Our company was awarded a pilot heart failure disease management program in VISN 17. I am also a practicing internist and geriatrician, and am intimately familiar with the long term and chronic care needs of veterans from my five years of practice at the Philadelphia VA Medical Center.
The Disease Management Association of America is a non-profit, voluntary membership organization, representing all aspects of the disease management community.
DMAA has established an industry-standard definition for qualified DM programs and entities. This definition, established in consultation with primary care and specialty physicians and representing private practice, health plan, and institutional perspectives, is as follows:
Disease management is a system of coordinated healthcare interventions and communications for populations with conditions where patient self-care efforts are a significant factor in supporting the physician/patient relationship and their plan of care;
Disease management emphasizes prevention of exacerbations and complications by utilizing evidence-based practice guidelines and patient empowerment strategies; and
Disease management evaluates clinical, humanistic and economic outcomes on an ongoing basis with the goal of improving overall health.
• Disease management services provided to an individual must include:
Population identification processes;
Evidence-based practice guidelines
Collaborative practice models to include physician and support-service providers;
Patient self-management education (e.g. primary prevention, behavior modification programs, and compliance/surveillance);
Process and outcomes measurement, evaluation and management, and routine reporting; and
A feedback loop (e.g. communication with patient, physician, health plan, and ancillary providers and practice profiling)

Disease management programs have become widely utilized by almost all commercial payers and nearly fifty percent of state Medicaid programs. Through the use of DM programs, public and private payers are seeing improvements in health status and quality of care, as well as, reductions in costs for their vulnerable populations with chronic diseases. Indeed, Medicare is about to launch a landmark set of chronic care improvement projects (e.g. MMA Sec. 721) in the fee-for-service (FFS) population this summer to provide heart failure and diabetes programs for our nation’s elderly.
Support for VA disease management and telehealth initiatives
DMAA strongly encourages and supports the Veterans Administration’s (VA) adoption of telehealth initiatives. The VA has done extensive evaluations of telemonitoring devices which have demonstrated their efficacy in improving patient health status and reducing avoidable utilization of VA acute care resources. 1 The VA’s use of telenursing is in an earlier stage. Telenursing leverages the telephone as a no-additional cost and nearly universal device to establish a therapeutic relationship between nurses and patients for education, counseling, and monitoring. Our members have demonstrated the value of using the telephone across a variety of settings to improve the health of vulnerable populations cost-effectively. To that end, we strongly
1 VISN 8 Community Care Coordination Service – Service Overview.
http://www1.va.gov/visn8/v8/clinical/cccs/service/overview.asp
encourage the VA to leverage the ubiquity and utility of the telephone in its telehealth initiatives. Indeed, the VA is beginning to measure the value of telenursing programs with its population. A pilot cohort study in VISN 17 will begin in the fall of 2005 to compare heart failure patients in the South Texas Veterans Health Care System who receive a DM intervention to those in the Central System who are not receiving the intervention.
Rural health
A recent study showed that the health of veterans who live in rural areas is worse than those who live elsewhere, even after adjusting for socioeconomic factors.2 Telehealth improves access to care for rural veterans with chronic conditions. It is also a valuable service for impoverished veterans who live in urban areas and are unable to travel easily to clinics. Telehealth overcomes many of these geographic barriers to care by employing telenursing, telemonitoring, and clinical decision support tools to educate and monitor veterans where they reside. As a result of increased experience in providing these services, increased scale and technological advances, the cost of providing telehealth services has lessened considerably. Expensive home visits by nurses can be reserved for those who are unstable.
2 Weeks WB, Kazis LE et al. Differences in health-related quality of life in rural and urban veterans. American Journal of Public Health. 94(10), October, 2004: 1762-1767.
Long term care
Telehealth initiatives, including disease management programs, have also been shown to decrease over-utilization, particularly nursing home admissions and stays.3 As an “aging in place” solution, telenursing, both separately and as a vital part of disease management programs have shown tremendous value in Medicare managed care settings. Caregivers of seniors, in particular, benefit not only from better understanding symptoms and the treatment plan, but also from the emotional and social support and reinforcement that telenurses provide. We recommend further research and pilots in the VHA setting.
Mental Health
In 2003, seventeen percent of veterans sought specialized mental health services from a VA facility. Estimates of substance abuse range from 22 to 29 percent of veterans. Rates of depression, anxiety, and psychotic disorders are much higher than the general population.4 Telehealth services can play a critical role in two domains pertaining to mental health. For patients with common chronic diseases such as heart failure or diabetes, mental health disorders, particularly depression, occur at alarming rates – ranging from 24 to 42 percent in a recent review article.5 In our experience, telenurses
3 Berg GB, Wadhwa, S and A Johnson. A matched-cohort study of health services utilization and financial outcomes for a heart failure disease-management program in elderly patients. Journal of the American Geriatrics Society. 52(10) October, 2004: 1655-1661. 4 US Medicine Institute for Health Studies. The Changing Face of Mental Health Services in the Veterans Health Administration. October, 2004. http://www.usminstitute.org/MHExecSummaryOct04.pdf 5 Guck TP, Elasasser GN et al. Depression and congestive heart failure. Congestive Heart Failure. 9(3). May-June, 2003:163-169.
provide relief from social isolation and anxiety, thus decreasing the need for mental health services. Telehealth solutions can also promote medication adherence; preliminary results of medication reminder systems with telemonitoring capabilities have demonstrated success in improving adherence to therapy in patients with schizophrenia.
Summary
In conclusion, disease management, care coordination and telehealth solutions already play an important role in the treatment of veterans, and, with appropriate fostering, they can play an even greater role. We strongly encourage the VA to promote and evaluate telenursing as well as telemonitoring interventions. DMAA commends the leadership shown by this Subcommittee and the Administration to promote the value of all of these initiatives and welcomes the opportunity to share our members’ experiences.
Again, Mr. Chairman and Ranking Member of the Subcommittee, thank you for the opportunity to present testimony today. We look forward to working with you and your staff to realize our shared vision of better care for our nation’s veterans. At this time, I would be happy to answer any questions from you or the other Members of the Subcommittee.