We talk to Chris Coloian, Senior Vice President Health Services at Health Dialog, a US population health and health improvement company owned by UK healthcare insurer BUPA.

Chris is the former vice president of health advocacy at CIGNA Healthcare, where he provided strategic, product, and marketing direction for the company’s portfolio of care management and health coaching programs.

HCE: How do you see the European market for chronic disease management programmes growing over the next few years?

CC: Very fast, maybe doubling in the next few years. I see no reason why in 2-3 years it shouldn’t be 20-25% of the US market, which today is around $2.5bn and growing at 10-15% a year.

HCE: Why this very fast growth?

CC: I think European policymakers, like our own president, really 'get it'.

HCE: Hmm, I hear mixed reports. In the USA, where people stay with insurers for 4-5 years, I’ve heard that chronic disease management programmes make sense, as they effectively reduce the acute care that an individual will need over that limited time period.

But people in Europe tell me that it is different for healthcare payors like UK primary care trusts, who will be paying out until the person dies. In those circumstances, do these programmes really deliver savings?

CC: To understand the full impact on society, one has to look past medical costs and consider productivity and contributions, such as increased tax revenue. You may extend someone’s life by, say, 2-5 years, but you will also have a much more healthy individual, who will be able to contribute more.

The studies I have seen show that this productivity bonus far outweighs any extra costs. And the cost of the extra few years is not very great anyhow, as most of the costs for any individual are incurred in the last six months of life. I think European policymakers and politicians understand this.

HCE: What makes Health Dialog unique in Europe?

CC: We go beyond the delivery of a turn-key service, and are willing to work with national health services and insurance companies as a consultant-advisers, and to provide intellectual property and tools.

I think in Europe many governments and healthcare systems will want to deploy existing resources to cover the area, rather than bring in a new sub-contractor.

Certainly, that has been the pattern in France, and I think the UK is also likely to go that way. Maybe Germany, where there are fewer primary care physicians, will follow the US example ,where projects are outsourced more, but it is too early to say.

HCE: So today you are active in the UK, France and Spain. Have you plans to go elsewhere?

CC: Yes, in the UK we are working with a couple of primary care trusts, in France we are working with the French government on project Sophia, and in Spain we are working with Sanitas, another BUPA company which is an insurer, runs hospitals and care homes.

HCE: How do the different European markets differ?

CC: I think the Europeans are taking a very thoughtful and considered approach. They are keen to implement chronic disease management programmes into their existing infrastructure, particularly into existing primary care networks.

What we have learnt in the USA, is that these programmes do work best when they are integrated, so there is an opportunity for Europe to leapfrog the initial turnkey solution stage.

Overall, the UK, like the USA is decentralised, with 152 different PCTs in England alone. Spain looks more decentralised, in that it has 17 regions each with a lot of independence; they have a lot more authority than UK primary care trusts, and can make big decisions that affect substantial primary care resources. However, as there are only 17 of them, Spain is still, in effect, a more centralised market.

HCE: And the US market? How is it faring? There is an article on Wikipedia which suggests that chronic disease management programmes remain unproven as cost savers. Weren’t there a lot of aborted Medicare and Medicaid projects?

CC: Growth has slowed since the early 2000s, but a lot of large insurers and payors, people like United Health and Aetna and providers like the Mayo and Cleveland clinics, are ploughing money internally into setting up these systems.

Commercial health plans have deployed a large percentage of their health improvement dollars on these programmes, and are showing no abatement in that focus.

A large Medicare fee-for-service project was aborted - but this reflected problems at Medicare around data, with many patients selected two years before intervention!

The Medicare Advantage Programme, through commercial insurers, is still actively deploying and running programmes. Programmes through Medicaid was one of the fastest growing segments until the economic downturn. But the really significant thing is the continuous and increased investment and interest from the major private payors and providers.

HCE: So have chronic disease management programmes been proven? I hear claims that they cut costs by 15-16%.

CC: I’d say yes, that is a fair number where the patient group is carefully targeted so that you exclude those people who are successfully self-treating. You want to focus on those individuals who are not already compliant, or who are having other problems.

HCE: I guess the most scientific way to prove the approach is to run controls, but that is very difficult isn't it?

CC: It is hard, yes, particularly to come up with comparative groups, but in the USA we do see controls, particularly on larger projects where 15-20% of those covered are being put on a chronic disease management programme or being treated as 'vulnerable', due to health risks such as weight or other conditions.

The control group would be utilized in the initial first or second year of the programme to validate its impact and results, then from that point forward it may or may not be continued.

HCE: What about monitoring devices? Talking to the device technology industry they seem to be bedevilled with tiny pilots and feel very frustrated that larger scale projects and programmes have not got off the ground yet.

CC: Yes, it is a bit like that in the USA too. The issue is that these devices are expensive, typically costing $50-$250 a month to run. So they have to show real cost benefit. Remote monitoring by patients is not really that necessary, given that most people in the USA actually live close to a clinic or a hospital.

The bottom line is that these devices have to prove that they can be predictive, that by continuously measuring something, whether it is weight, blood pressure, or whatever, you can make changes to treatment which will have an impact and pay for the device and its monitoring.

That has been shown for congestive heart failure, but not for many other conditions. So, yes, we are at the early pilot stage until these devices can prove they are fully cost efficient.

HCE: Thank you very much for the interview.