Moderator (Dr. Ajay Singh): Thank you Dr. Silverberg. We're now going to move on to the question and answer session. Before we start that session, I would like to first introduce to you one of our panelists who is here, Dr. John Dickmeyer. I'm sure many of you know Dr. Dickmeyer as being one of the leading clinical nephrologists in the country, but he's also the Senior Vice President of RMS Baxter, which is a leading national renal disease management company. So it's a real pleasure to have him join us on this panel. What I would like to do is start the question and answer session by taking the liberty of asking a question first and then we'll take questions from the audience.

Dr. Dickmeyer, in the setting of thinking about kidney disease care in the future, I want to ask you what's happening with renal disease management nationally? Can you give us an update of what's happening with RMS Baxter and the other companies that are out there?

Dr. Dickmeyer:
Just a couple of comments about disease management.
As many of you know, this concept was described first by the Boston Consulting Group in, I think, 1993. It basically held the premise that if you identify those 20% of the patient population within a health plan that were indeed responsible for 80% of the cost, and you developed focused management programs for those patients, that healthcare costs could be significantly controlled. As a result of that initial paper, there were a number of companies formed that not only focused on integrating with health plans to identify those patients that indeed were the high cost patients, but also disease management companies were formed for congestive heart failure, for diabetes, for asthma. They have worked with insurers. What they do is once those patients are identified from a claim set, those patients are called on a regular basis by one of these disease management companies, usually through one of their nurses. Just calling a patient on a regular basis, working with a patient so the patient knows guidelines of care. So the patient understands they would need Hemoglobin-AIC, they know they need to be free of edema. There has been a significant improvement in the cost of care with a number of these health plans for these chronically ill patients.

Disease management program focusing on high risk patients
I became involved in this in 1996. It's very exciting to see, I think, these discussions today because we're moving now from a focus just on ESRD to this focus on CKD, which I think is very exciting. When we developed our disease management program, it was our premise that if we provided the same type of regular visits to these patients, and if we could identify the high risk patients in the ESRD population, that indeed we could improve the outcomes for ESRD. Basically, our medical management model consists of an extensive assessment program for the patient in their home with their family. We use the index of coexisting disease and the index of physical impairment to risk adjust the population. Those high risk patients are literally called on a daily basis. We integrate with their families and what have you. So what actually happens is that we provide additional nursing support to the physicians and we collect a lot of data and bring that back to the nephrology community.

Effects of a disease management program
As a result, we were actually quite surprised. We published this data in the American Journal of Kidney Disease this past May (Nissenson A et al, Am J Kidney Dis. 2001 May;37(5):938-44.) Hospitalization was reduced by 30% when we compared our population to the HCFA population on a risk-adjusted basis and mortality decreased by 20%. We looked back at our data and what we found to be probably the single-most factor, single-most significant factor that led to those improvements was the focus on comorbidity management. Initially, we made sure that the core indicators were met with these patients, but then we moved on to diabetes care. We found that many of our patients didn't have regular Hemoglobin-AIC. Their wounds were not being addressed. The heart failure was not being addressed by either maintaining the normal hemoglobin or keeping free of edema.

Guidelines of care
We developed guidelines of care for the cardiovascular management to make sure that the patients who had cardiovascular disease were on beta blockers. So I think that we're going to see an evolution, as we focused not on the ESRD patient, but on the CKD patient, an evolution towards comorbidity management. I think that we'll see significant improvement in the ESRD population, as well as the CKD population.

So what I am hearing from health plans is that they believe in disease management. What I am hearing from health plans is that employers are insisting on disease management programs if that insurer is going to be the insurer of choice for the employer. So I believe that disease management will continue to grow and to evolve. Thanks.

References

Nissenson AR, Collins AJ, Dickmeyer J, Litchfield T, Mattern W, McMahill CN, Muhlbaier L, Nielsen J, Owen WF Jr, Pereira BJ, Steinman TI, Szczech L. Evaluation of disease-state management of dialysis patients. Am J Kidney Dis. 2001 May;37(5):938-44.