What is a 'Disease Management Program'

A disease management program is an initiative created and managed by a health insurance company to manage the costs of policyholders’ chronic health conditions. It is based on the idea of spending a relatively low impact now to prevent or minimize health problems to lessen potential costs and related claims in the future.

BREAKING DOWN 'Disease Management Program'

A disease management program can help control health care expenses for insurance companies and employers who offer health insurance.

These programs identify individuals who have or may be at risk for developing a chronic condition, use evidence-based practices to manage the condition and mitigate the risk of expensive treatments, and coordinate care among the several health care providers the individual may see. They also teach the patient prevention and behavior modification methods to minimize the risk of developing the condition or to manage a condition that has already developed.

Disease management programs provide support for ongoing health problems such as diabetes, coronary artery disease, asthma, cancer, high blood pressure, back pain, kidney disease and depression. These programs use strategies such as putting members in touch with nurses who can answer questions by phone and email or via telemedicine systems without the need for a doctor visit; analyzing claims and other health information to look for possible treatment gaps; and educating patients about things they can do to prevent or mitigate the condition, such as exercising to prevent heart disease.

How Disease Management Programs Save Money

By implementing a disease management program, insurance companies and employers who provide health insurance can minimize costs and maintain a healthy workforce by proactively managing health-related risks. Wellness programs that offer incentives to exercise, eat well, quit smoking and take other basic steps toward good health can complement disease management programs.

Disease management initiatives aim to reduce the need for expensive hospitalizations, procedures and surgeries for chronic problems, because these are often the most expensive problems to treat. The idea is to manage the patient’s care on an ongoing basis, not just to treat them when a crisis arises. The theory is that by investing a certain amount into proactive and preventive measures the insurance company or employer can help the insured avoid problems that could result in much higher claims later on. So despite the initial upfront cost, this can prove to be a financial positive and profitable tactic for the insurer. Disease management is one way to mitigate the impact of continually increasing health care costs.

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