Carve-Outs

Abstract

Disease management is a strategy for patient care across the entire healthcare delivery system and throughout the life-cycle of a disease. Disease management is a new paradigm for managed care. It focuses on an alignment of interests between patient, payor and provider.

But what is a carve-out, and what is its role in disease management? Is it an interim step to a disease management programme? Is it a subset of a disease management programme? Does a carve-out have benefits as a stand alone programme? This article addresses these questions by looking at both heart and cancer carve-outs versus disease management. Through these 2 examples, the parameters for disease management and carve-outs are compared.

Carve-outs treat the episodic events of a disease and are effective when the disease is independent of other patient conditions, when the disease has a defined beginning and end, and when treatment for the disease is predictable and definable. When a disease has many interdependencies or cause-effect relationships with other conditions, disease management offers the best method of providing treatment for the complete life-cycle of the disease.

‘Managed care’ began by managing access to goods and services, has matured to managing episodes of acute/costly care needs and is gradually migrating to managing the continuum of care needs for optimised outcomes.

By implementing disease management programmes for serious and catastrophic diseases, managed care will be evolving to the next step in the process of providing quality healthcare while holding costs to acceptable levels.