Measuring Health Plans' Disease Management Programs - Disease Management Effectiveness Project (DMEP)

Problem: Chronic illness takes its toll on quality of life and productivity of millions of Californians, and through high costs as a percentage of total health care expenditures. As the population ages, there is a corresponding increase in the incidence of those with multiple chronic illnesses. This makes the need for disease management programs more important than ever—to both detect and manage illness. Survey results also reveal that it is the chronically ill who are the least satisfied with their health plans in California. Providing better coordinated care to the chronically ill is the promise of managed care. Purchasers want to see health plans deliver on this promise. Finally, Pacific Business Group on Health members seek the ability to compare plans on the basis of quality—in order to recognize and reward quality differences among health plans through plan selection and contribution strategies.

For all these reasons, PBGH members are vitally interested in the promise and implementation status of disease management (DM) programs offered by California health plans. Purchasers and health plans believe in the potential of these programs to substantially improve health and/or reduce costs, but share concerns about the extent to which the current programs meet these goals. The delegated model in California wherein medical groups are the primary locus of care adds a layer of complexity to assessing the efficacy of care management programs. Before determining the extent to which disease management can address cost and quality, a baseline of how well the health plans are currently performing is needed.

A review of known best practices in disease management, criteria for evaluation and an evaluation tool were developed in consultation with national experts and participating health plans along with detailed condition specific information gathering tools. The approach included making maximum use of information obtained through the 2001 PBGH RFP process conducted for the Negotiating Alliance and did not rely on a single set of published DM standards. The RFP responses were supplemented with more focused questions and analysis of plan-specific disease management protocols and outcomes and on-site reviews with the plan's DM leadership team. The review was supplemented by a separate analysis of case files that enabled the team to evaluate the processes used by the plans to manage these patients.

The project is fully funded through the PBGH Quality Improvement Fund to which all PBGH members contribute. In addition, the participating health plans provided substantial investment in their staff time to prepare material for the review. Under the direction of PBGH, a consultant with special expertise and significant experience in disease management was retained to develop, implement and oversee the project with the assistance of PBGH staff.

Impact: This project assessed the extent to which DM programs are fulfilling their promise. Results are being used to identify best practices, develop performance requirements and improve tracking mechanisms for the future. All PBGH members received detailed reports based on the project and areable to use this information in their contracting and health plan collaboration efforts. Participating health plans received detailed reports on their own performance and blinded comparisons to other plans. The project report should be valuable for their own quality improvement purposes.

Current Activities: For a summary of some of the general report conclusions, view this slide presentation of remarks given by Peter V. Lee, PBGH President and CEO, at the National Coalition on Health Care Conference on May 16, 2002. Or click here to view the final report.

Having delivered an initial report in 2002 to health plans and PBGH members, the Disease Management Effectiveness Project is now part of the broader mission of the Breakthrough Strategy, which is operating on many fronts to push health plans to be more accountable for the quality of care they arrange.

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