When DM first gained critical mass in managed care, there was no set of uniform guidelines to evaluate the success of DM programs. Four years ago, DMAA: The Care Continuum Alliance (formerly the Disease Management Association of America) was the first to offer guidance.

Working with its corporate and individual members, as well as with external stakeholders, including The Joint Commission and the National Committee for Quality Assurance (NCQA), the DMAA unveiled Volume I of its guidelines on recommended practices for measuring outcomes in December 2006. Volume II was released just a few months ago, and DMAA plans to release additional volumes during the next several years.

Dr. Norman compares the situation with what existed for health plans 20 years ago, before the promulgation of HEDIS, where various clinical and other measures of population healthcare were collected by NCQA and publicly reported so buyers could get a comparative sense of performance.

Development of a broadly accepted approach to DM program evaluation, using key statistical and actuarial practices, will permit health plans, employers, state and municipal governments, and other purchasers to more clearly understand the clinical and financial value of disease management and make better-informed purchasing decisions. Increasingly, the guidelines are being used as an aid in developing contractual terms for assessing DM programs in the public and private sectors, Dr. Norman says.

MHE Executive View

THE GUIDELINES

Among DMAA's recommended guidelines in Volume I is the use of a pre-post study design that incorporates, when possible, an equivalent, concurrent comparison group; measurement methods for program identification, qualification for evaluation and the principle of equivalence between baseline and intervention groups; and a measurement period of one year for baseline and subsequent years.

The guidelines also include a tool to assess the financial impact of a program, as measured by changes in total dollars or per-member per-month charges for paid or allowed medical and pharmacy claims; use of non-chronic population to calculate trend; and agreement on a mutually acceptable risk adjustment method.

Volume II adds clinical outcome measures developed jointly with NCQA. It also includes a wellness-program model and definition, and recommendations for evaluating the impact on small populations—two areas identified through open comment on Volume 1 as needing development.

Another change in Volume II is the identification of chronic patients. Volume I recommended either annual qualification (requalifying each year) or prospective identification (once selected, always selected). Volume II recommends annual qualification only. Also in Volume II, DMAA added the Disease Management Purchasing Consortium's "plausibility indicator" and other utilization measures.

The plausibility indicator is a measure based on rates of adverse events to see if they decline when a DM program claims to show savings, says MHE Editorial Advisor Al Lewis, executive director of Boston-based Disease Management Purchasing Continuum LLC.

"If you claim savings on asthma, it should be the case that asthma attacks go down across your book of business," he says.

Lewis says he expects DMAA to add the DMPC "dummy-year analysis" tool to the guidelines in the next one to two years. This tool tests whether the use of the methodology by itself has an effect on the measurements.