A Call for Best Practice

The Disease Management (DM) Industry is at a crossroads. With health care costs on the rise and a changing economy, programs are no longer just employee benefits, they have to produce results. Employer groups are ready to see evidence that the programs are generating positive health outcomes and that they are indeed working.

According to the Disease Management Association of America (DMAA), successful DM programs include population identification practices, evidence-based practice guidelines, collaboration models with the entire care team, education, and outcomes measurement. The primary purpose of these programs should be to improve overall health and reduce health care costs related to chronic conditions. DM programs must provide all of this under a cost effective program built on reliable and valid data.

Threats to Validity of Program Outcomes
Potential sources of bias must be identified and controlled when developing program evaluation strategies. Take selection bias, for example. The most valid method for selection bias is to introduce a control group. If the intervention group improves and the control group stays the same, then you have a successful program. Another area that requires attention is regression to the mean. This can be controlled by using a pre and post measurement for both the intervention group and the control group. It is also important to measure programs over several years in order to show movement outside of just the regression to the mean.

To give an example, researchers from the Indiana University School of Medicine designed a study to determine whether chronic disease management of individuals with diabetes and/or congestive heart failure (CHF) improves health outcomes and lowers health care costs. In contrast to earlier studies, the researchers randomly assigned individuals with the two chronic conditions to either chronic disease management or a control group based on their primary care provider’

s location. The researchers used a predictive model to identify individuals at risk for high levels of future health care utilization.

Individuals judged to be at highest risk were given intensive health care management conducted by a Care Manager. Those with lower risk were provided with education and care support as needed over the phone. Their findings were very positive. “The telephonic support resulted in a significant reduction in subsequent health care claims paid,”

 said study senior author Thomas S. Inui, M.D., IU School of Medicine.

One of the strengths of this evaluation is that the fiscal impact analysis included the costs of delivering the chronic disease management intervention, not just the impact on claims for subsequent utilization.

Disease management has and is proving to be an effective claims control measure. The model that will most impact program outcomes is the one that can produce valid and reliable results using control groups and predictive risk scores. DM vendors must also be willing to include their fees in a claim cost analysis. The programs must be cost effective to produce a real return on investment.

The Disease, Maternity, and Lifestyle Management Programs at GPA use the above practices in evaluating our programs. Our statistical methods have been evaluated and approved by URAC.

For more information about our programs, please contact wellness@gpatpa.com.