Analysis of Disease Management

An organized, proactive approach to health care for members of a population with a specific disease or a combination of diseases - or care designed to prevent the development of specific diseases in those at risk. The aim of disease management is to increase the delivery of appropriate care to enrolled patients. Policy options focus on expanding the use of disease management in public and private insurance programs.

These are the nine performance dimensions against which we measured Disease Management:

Spending

There is mixed evidence about the effect of disease management on overall health spending:

  • In theory, disease management programs use up-front investments in care management services to achieve savings through decreased treatment costs over the longer term. Read more below
  • Evidence is mixed on the effect of disease management on spending. Read more below
  • Disease management approaches vary widely. The effect of disease management on spending may differ depending on the disease management approach or the disease targeted. Read more below

In theory, disease management programs use up-front investments in care management services to achieve savings through decreased treatment costs over the longer term.

Disease management (DM) programs attempt to improve the delivery of care to patients with chronic disease via self-care management techniques, patient education, provider training, and individualized care plans based on clinical guidelines. In theory, if patients with a chronic disease receive better preventive and maintenance care, they will have fewer disease complications and require less intensive and less expensive care. Given that spending on the 30 percent of people with chronic disease accounts for more than 75 percent of health spending in the United States—over $1.5 trillion—improved DM could potentially yield significant savings (CDC, 2005). On the other hand, DM does require a significant up-front investment in health care spending, and the net balance of spending to savings remains unclear.

Evidence is mixed on the effect of disease management on spending.

Evidence from controlled studies of disease management on spending is mixed. Mattke, Seid, and Ma's (2007) review of the DM literature found inconclusive evidence of the effects of DM on spending for the most commonly targeted diseases, including congestive heart failure (CHF), coronary artery disease (CAD), and diabetes, whereas costs increased for depression. The DM firms participating in the Medicare Health Support demonstration are required to achieve budget neutrality. That is, fees charged to Medicare for managing participants must be at least equal to savings from better management, but early results indicate that the fees have not been so (McCall, Cromwell, and Bernard, 2007). RAND's Improving Chronic Illness Care Evaluation (ICICE) had cost offsets from reduced hospitalization for CHF, but not for diabetes or asthma, which had a higher number of visits. Earlier scientific research shows some positive cost results for CHF (Rich, 1999) and diabetes (Bodenheimer et al., 2002). However, such research is often conducted with selected high-risk populations, making the programs more like case management than population DM (RAND Corporation, not dated).

A description of the evolution of disease management programs in managed care found that they had voluntary participation by enrollees, targeted behavior change, and improved patient self-management; were focused narrowly on those patients and diseases for which expected benefits clearly exceed expected costs; and were designed to produce a positive return on investment, largely by using approaches that require small investments (Robinson and Yegian, 2004).

Since many studies do not address the issue of cost but rather focus on quality of care and outcomes, it is difficult to generate conclusive evidence proving that DM can lead to a net cost savings (Mattke, Seid, and Ma, 2007).

Disease management approaches vary widely. The effect of disease management on spending may differ depending on the DM approach or the disease targeted.

There is tremendous variability among DM programs, and the effects on spending may differ depending on the targeted disease and type of program. Mattke, Seid, and Ma (2007) describe the variation among DM programs along two dimensions: severity of illness among the target population and intensity of the intervention. Some DM programs target chronically ill patients with severe disease, whereas others focus on all patients with the disease regardless of severity, including individuals who may be just at risk of developing the disease. Programs vary in the intensity of the interventions, which can range from mailings to face-to-face encounters with disease managers.

DM may also cause shifts in health care spending among types of services. For example, patients who improve adherence to drug therapy will see an increase in pharmacy costs. Similarly, a primary goal of DM is to improve the coordination and continuity of care with the patient's health care provider. Thus, we would expect to see increases in the volume of outpatient visits to the primary care provider and, as a natural extension of such increases, increased laboratory and radiological diagnostics relevant to the disease and its related complications and comorbidities.

Ultimately, the effect of DM on spending will clearly depend on the targeted diseases, the severity of the illness, and the intensity, costs, and duration of the program.

References

Bodenheimer T, Lorig K, Holman H, Grumbach K, "Patient Self-Management of Chronic Disease in Primary Care," The Journal of the American Medical Association, Vol. 288, No. 19, November 20 2002, pp. 2469-2475.

Centers for Disease Control and Prevention (CDC), "Chronic Disease Overview," Chronic Disease Control and Prevention page. November 2005. As of November 15, 2008: http://www.cdc.gov/nccdphp/overview.htm

Mattke S, Seid M, Ma S, "Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?" The American Journal of Managed Care, Vol. 13, December 2007, pp. 670-676.

McCall N, Cromwell J, Bernard S, Evaluation of Phase I of Medicare Health Support (formerly Voluntary Chronic Care Improvement) Pilot Program Under Traditional Fee-for-Service Medicare, Report to Congress, June 2007.

RAND Corporation, Improving Chronic Illness Care Evaluation (ICICE), Santa Monica, Calif.: RAND Corporation, Web site, not dated. As of November 6, 2008: http://www.rand.org/health/projects/icice/

Rich, M, "Heart Failure Disease Management: A Critical Review," Journal of Cardiac Failure, Vol. 5, No. 1, March 1999, pp. 64-75.

Robinson JC, Yegian JM, "Medical Management After Managed Care," Health Affairs, Web Exclusive No. 4, May 2004, pp. w.269-w.280.

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Consumer Financial Risk

There is little evidence regarding the relationship between disease management and consumer financial risk:

  • There are no studies that evaluate the effect of disease management on consumer financial risk. Read more below
  • In theory, if disease management changes the patterns of health care use, there may be changes in consumer financial risk. Read more below

There are no studies that evaluate the effect of disease management on consumer financial risk.

To estimate changes in consumer financial risk, we would need to understand expected changes in health care use and patient cost sharing responsibilities.

No literature has examined the effect of disease management (DM) on consumer financial risk. Mattke, Seid, and Ma's (2007) review of the literature found that DM reduced hospital admission rates for patients with congestive heart failure and increased use of services for depression. It otherwise found inconclusive evidence that DM changed the utilization of services for coronary artery disease, asthma, and chronic obstructive pulmonary disease (COPD).

We do not conclusively know whether DM programs affect patterns of health care use, so the effects on consumer financial risk are unclear. Even if the literature were more extensive, it would be difficult to predict how DM would affect the financial responsibilities of a given patient.

In theory, if disease management changes the patterns of health care use, there may be changes in consumer financial risk.

DM programs attempt to improve the treatment and management of chronic diseases so that complications can be avoided or minimized. To this end, they may encourage patients to seek more frequent outpatient care, increase diagnostic testing, and increase use of pharmaceuticals. In doing so, these programs try to avoid the use of more costly medical services, such as emergency department visits and hospitalizations. If DM programs succeed in changing patterns of health care use, there may be changes in consumer financial risk. Patient cost sharing may differ between inpatient and outpatient care, so changes in health service use could affect costs to patients.

If DM programs alter health care use patterns, changes in the individual's financial risk will depend largely on his or her health insurance coverage. Patients with Medicaid, for example, have little or no cost sharing, so any potential changes in use of health care resources will not have a financial effect on them. Beneficiaries of Medicare and private plans may have variable patient cost sharing requirements for inpatient and outpatient care and other ancillary services, so their cost responsibilities may change.

References

Mattke S, Seid M, Ma S, "Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?" The American Journal of Managed Care, Vol. 13, December 2007, pp. 670-676.

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Waste

There is no evidence that disease management affects waste:

  • Theory suggests that if disease management leads to a reduction in avoidable emergency room visits and hospitalizations, then clinical waste may decrease. Read more below
  • Alternatively, disease management programs may add a layer of complexity to the delivery of health care that may contribute to waste in the health care system rather than reduce costs. Read more below

Theory suggests that if disease management leads to a reduction in avoidable emergency room visits and hospitalizations, then clinical waste may decrease.

The goal of disease management (DM) programs is to improve the care of patients with a chronic disease so that expensive, potentially avoidable, and arguably wasteful care can be averted. To this end, DM programs encourage the use of appropriate services for patients with a chronic disease.

To understand the relationship between DM and waste, we would have to understand how DM affects the efficiency of care and whether patients receive appropriate care in less costly settings.

Though there is little evidence on the relationship between DM and waste, we would expect that the relationship may be complex and will depend on the particular program and targeted disease.

No literature directly examines the relationship between DM and waste. Whereas DM was found to reduce hospitalization rates among congestive heart failure (CHF) patients (Mattke, Seid, and Ma, 2007), the effect on other diseases has not been demonstrated. DM programs offer services for as many as 20 to 30 different conditions; however, there is inconclusive evidence that the programs are effective or improve the efficiency of care.

Alternatively, disease management programs may add a layer of complexity to the delivery of health care that may contribute to waste in the health care system rather than reduce costs.

Programs typically encourage patients to have regular follow-up with their physicians; however, many DM programs do not integrate significantly with these physician practices. Without such integration, these programs may add another layer of services and complexity to an already fragmented health care system. If that layer does not save costs, it may actually increase waste.

References

Mattke S, Seid M, Ma S, "Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?" The American Journal of Managed Care, Vol. 13, December 2007, pp. 670-676.

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Reliability

Evidence from the literature suggests that disease management improves the reliability of care:

  • Multiple studies have found that disease management programs improve processes of clinical care so that participants are more likely to receive recommended care. Read more below
  • One limitation of the current literature on disease management is that it may not adequately account for the long-term trends that have resulted from systemwide improvements in quality of care. Read more below

Multiple studies have found that disease management (DM) programs improve processes of clinical care so that participants are more likely to receive recommended care.

Disease management programs optimally use evidence-based clinical guidelines and best practices to design interventions for patients with chronic disease. So, for example, patients with diabetes are encouraged to have more regular A1c (glycated hemoglobin) screenings and eye exams. By targeting chronically ill patients with specific appropriate clinical interventions, DM programs should improve the reliability of care. Changes in the reliability of care resulting from DM programs may vary depending on the disease targeted by the program.

We assume that DM programs can improve communication, management, and follow-up for patients with chronic and costly conditions and therefore could improve reliability (Fireman, Bartlett, and Selby, 2004).

Current literature suggests that DM improves clinical processes of care for a variety of diseases. Both RAND's Improving Chronic Illness Care Evaluation (ICICE) (Tsai et al., 2005; Vargas, 2007) and the review by Mattke, Seid, and Ma (2007) found process improvements for diabetes, congestive heart failure, depression, and asthma. Norris et al. (2002) and Glazier et al. (2006) also found increased use of recommended exams and improved use of appropriate diet and medications in patients with diabetes. Fireman, Bartlett, and Selby (2004) reviewed quality measures when they studied a Kaiser Permanente program in Northern California that incorporated DM principles into a multidisciplinary practice for patients with coronary artery disease, heart failure, diabetes, and asthma. The study's quality indicators measured the use of recommended tests and medications, and the control of risk factors. The authors found that the percentage of patients receiving recommended tests and medications increased for each condition.

Using two quasi-experimental methods, Villagra and Ahmed (2004) analyzed the first-year results of multistate diabetes disease management programs sponsored by a national managed care organization. In both analyses, quality scores in the DM sites were significantly better than in sites without the program. Differences reached statistical significance for dilated retinal exam, microalbumin testing, lipid testing, and tobacco use. In addition, diabetes-related Health Employment Data and Information Sets (HEDIS; quality measures) and non-HEDIS metrics improved when a DM program was in place.

One limitation of the current literature on DM is that it may not adequately account for the long-term trends that have resulted from systemwide improvements in quality of care.

Coincident with the increase in popularity of DM programs has been a national focus on the poor quality of health care in the United States (Committee on Quality of Health Care in America, 2001). As a result, there have been many interventions to measure the effectiveness of care and to improve quality. The existing literature on DM does not consistently account for long-term trends in the reliability of care and so may overestimate the effects of DM on processes of care.

References

Committee on Quality of Health Care in America, Institute of Medicine (IOM), Crossing the Quality Chasm: A New Health System for the 21st Century, Washington, D.C.: Institute of Medicine, National Academy Press, 2001.

Fireman B, Bartlett J, Selby J, "Can Disease Management Reduce Health Care Costs by Improving Quality?" Health Affairs, Vol. 23, No. 6, November/December 2004, pp. 63-75.

Glazier RH, Bajcar J, Kennie NR, Willson K, "A Systematic Review of Interventions to Improve Diabetes Care in Socially Disadvantaged Populations," Diabetes Care, Vol. 29, No. 7, July 2006, pp. 1675-1688.

Mattke S, Seid M, Ma S, "Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?" The American Journal of Managed Care, Vol. 13, December 2007, pp. 670-676.

Norris SL, Nichols PJ, Caspersen CJ, Glasgow RE, Engelgau MM, Jack L, Isham G, Snyder SR, Carande-Kulis VG, Garfield S, Briss P, McCulloch D, Task Force on Community Preventive Services, "The Effectiveness of Disease and Case Management for People with Diabetes: A Systematic Review," American Journal of Preventive Medicine, Vol. 22, No. 4, Suppl. 1, May 2002, pp. 15-38.

Tsai AC, Morton SC, Mangione CM, Keeler EB, "A Meta-Analysis of Interventions to Improve Chronic Illness Care," The American Journal of Managed Care, Vol. 11, August 2005, pp. 478-488.

Vargas RB, Mangione CM, Asch S, Keesey J, Rosen M, Schonlau M, Keeler EB, "Can a Chronic Care Model Collaborative Reduce Heart Disease Risk in Patients with Diabetes?" Journal of General Internal Medicine, Vol. 22, No. 2, February 2007, pp. 215-222.

Villagra VG, Ahmed T, "Effectiveness of a Disease Management Program for Patients with Diabetes," Health Affairs, Vol. 23, No. 4, July/August 2004, pp. 255-266.

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Patient Experience

It is uncertain how patient experience would be affected by the use of disease management programs:

  • Although the evidence is limited, some studies suggest that disease management improves elements of patient satisfaction. Read more below
  • Disease management provides additional services to patients with chronic disease, and patients seem to welcome such services. Read more below

Although the evidence is limited, some studies suggest that disease management improves elements of patient satisfaction.

Disease management (DM) programs attempt to improve the delivery of care to patients with chronic disease. They do so through self-care management techniques, patient education, provider training, and individualized care plans based on clinical guidelines. The measure of patient experience is the extent to which health care is delivered in a manner that is respectful of and responsive to the patient's needs, preferences, and values. Patient satisfaction is an element of patient experience and refers to the degree to which patients regard the health care they receive or the manner in which they receive it as useful, effective, and beneficial. If DM programs increase continuity of care and disease control, patient satisfaction with care should increase. However, the study of the relationship between DM and patient satisfaction is limited by the lack of a valid and reliable patient satisfaction measurement tool for this purpose (Sen et al., 2005).

The quality and availability of services may depend on patient income and location. Ideally, services would be tailored to unique patient demographics (e.g., urban as opposed to rural).

In RAND's Improving Chronic Illness Care Evaluation (ICICE), patients felt that communication with providers improved, but there were no changes in overall satisfaction (RAND Corporation, not dated). A Robert Wood Johnson Foundation (RWJF)-funded study of a DM program for end stage renal disease found that kidney specialists saw DM program participants earlier and more regularly than patients covered under Medicare fee for service (RWJF, 2002). Mattke, Seid, and Ma's (2007) review of the literature found that while patient experience improved for patients with congestive heart failure and depression, there was insufficient evidence to draw conclusions about other diseases.

Disease management provides additional services to patients with chronic disease, and patients seem to welcome these services.

Patients in DM programs often choose to participate in these programs and receive the services for free, so their satisfaction would be expected to be high; however, patients who face mandatory enrollment or who have to pay for services may not experience the same level of satisfaction.

Little is known regarding the effect of DM on patient satisfaction. Few findings are generalizable to the larger U.S. population, and it is difficult to predict the rate of program adoption by patients. An area for further study is whether the Consumer Assessment of Healthcare Providers and Systems (CAHPS), a patient experience survey, could be used in conjunction with a DM survey to assess an association between DM and improved satisfaction with primary care service (and, e.g., health plan customer service).

References

Mattke S, Seid M, Ma S, "Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?" The American Journal of Managed Care, Vol. 13, December 2007, pp. 670-676.

RAND Corporation, Improving Chronic Illness Care Evaluation (ICICE), Santa Monica, Calif.: RAND Corporation, Web site, not dated. As of November 6, 2008: http://www.rand.org/health/projects/icice/

Robert Wood Johnson Foundation (RWJF), "Disease Management Program Reduces Hospital Days for Chronic Renal Disease Patients," Web page, May 2002. As of November 6, 2008: http://www.rwjf.org/reports/grr/032061.htm

Sen, S, Fawson P, Cherrington G, Douglas K, Friedman N, Maljanian R, Fitzner K, Tang P, Soper S, Wood S, "Patient Satisfaction Measurement in the Disease Management Industry," Disease Management, Vol. 8, No. 5, October 1, 2005, pp. 288-300.

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Health

While theory suggests that disease management should increase the delivery of appropriate care and improve health, there is yet no evidence to support this relationship.

  • Evidence suggests that disease management may increase the delivery of appropriate care, but the health effects of such care are uncertain. Read more below
  • The literature on disease management shows inconclusive or no effects on health, but the studies are limited by the short duration of health follow-up. Read more below

Evidence suggests that disease management may increase the delivery of appropriate care, but the health effects of such care are uncertain.

In theory, disease management (DM) should lead to improved clinical processes of care, reduced health risk behaviors, and improved disease control; these improvements should result in improved clinical outcomes. However, it can be challenging to isolate the effects of DM programs from other efforts to improve quality of care and long-term trends in health outcomes. In addition, the health effects of improved disease control may manifest only over the long term. We assume that health outcomes include both life expectancy and health-related quality of life.

Low-income and minority populations, which suffer from greater morbidity from chronic disease, may not experience the same level of health effects from DM programs as other groups. In addition, health effects of DM may vary by disease and severity of illness.

The literature on disease management shows inconclusive or no effects on health, but the studies are limited by the short duration of health follow-up.

While the evidence linking a reduction in risk factors to better future health is quite strong, the evidence linking DM to better future health is limited. In a randomized control trial of a Chronic Care Model (CCM) intervention for diabetes patients, the CCM group demonstrated significantly improved A1c (glycated hemoglobin, or blood glucose) and non-HDL cholesterol levels, as well as higher self-monitoring rates of blood glucose levels (Piatt et al., 2006). In a review of randomized trials of DM programs, McAlister and colleagues (2001) identified two DM trials for heart failure that found statistically significant reductions in hospitalizations. Mattke, Seid, and Ma's (2007) review of the literature found inconclusive evidence that disease management changes health outcomes for the disease studied.

Some researchers have modeled the anticipated effects of DM on health. One method is to assume the effect of management of a chronic disease and project the number of lives saved or estimate a rate of reduction in morbidities. In its Improving Chronic Illness Care Evaluation (ICICE), for example, RAND calculated that a DM program would lead to one fewer cardiovascular disease (CVD) event per 48 patients with diabetes (RAND Corporation, not dated).

Additional research is needed regarding the effect of DM programs on such illnesses as cancer and dementia, and on rare and expensive conditions such as hemophilia. The time frame of evaluations is insufficient, and preliminary evidence is inconclusive about the effect of DM on mortality or other health measures. More long-term follow-up is needed to measure the true health benefits of DM over time (Mattke, Seid, Ma, 2007).

We do not know whether DM affects some of the other issues in our health care system that end up contributing to poor quality medical outcomes, such as problems with process of care and medical errors.

References

Mattke S, Seid M, Ma S, "Evidence for the Effect of Disease Management: Is $1 Billion a Year a Good Investment?" The American Journal of Managed Care, Vol. 13, December 2007, pp. 670-676.

McAlister FA, Lawson FM, Teo KK, Armstrong PW, "A Systematic Review of Randomized Trials of Disease Management Programs in Heart Failure," The American Journal of Medicine, Vol. 110, No. 5, April 1, 2001, pp. 378-384.

Piatt GA, Orchard TJ, Emerson S, Simmons D, Songer TJ, Brooks MM, Korytkowski M, Siminerio LM, Ahmad U, Zgibor JC, "Translating the Chronic Care Model into the Community: Results from a Randomized Controlled Trial of a Multifaceted Diabetes Care Intervention," Diabetes Care, Vol. 29, No. 4, April 2006, pp. 811-817.

RAND Corporation, Improving Chronic Illness Care Evaluation (ICICE), Santa Monica, Calif.: RAND Corporation, Web site, not dated. As of November 6, 2008: http://www.rand.org/health/projects/icice/

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Coverage

Not applicable

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Capacity

No published studies examine the relationship between disease management and health system capacity; however, in theory, disease management may take resources away from other uses in the health care system:

  • We know of no studies that suggest that disease management would have an effect on capacity. Read more below
  • In theory, the nursing requirements of disease management programs may place additional pressure on the national supply of nurses. Read more below

We know of no studies that suggest that disease management would have an effect on capacity.

No published literature examines the relationship between disease management (DM) programs and capacity.

In theory, the nursing requirements of DM programs may place additional pressure on the national supply of nurses.

DM employs a large number of nurses to provide individualized telephone or in-person patient advice, education, and disease monitoring—a possible attractive alternative to nurses who do not want to work in direct health care delivery. The nursing shortage in the United States, and in direct care in particular, suggests an economic effect on health care of higher wages for those who do remain in service. It is unclear whether potential changes in health services utilization may offset the shortage of nurses in the hospital setting. DM may also shift some routine tasks to patients, reducing the demand for lower level staff to perform them.

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Operational Feasibility

Implementation of disease management would be relatively easy:

  • Implementing disease management is fairly straightforward, and disease management is already commonly used in the private and public sectors. Read more below
  • It remains unclear how well disease management programs can integrate with physicians' care of patients with chronic disease. Read more below

Implementing disease management is fairly straightforward, and disease management is already commonly used in the private and public sectors.

A number of fairly straightforward steps are involved in the implementation of a disease management (DM) program, including the identification of eligible patients, the provision of services, and the monitoring of patient progress and clinical status. It can be difficult, however, to integrate DM services with standard physician care. There is little evidence that third party programs can easily engage doctors, nor is there evidence that doctors, on the whole, are supportive of such programs.

Whether some doctors adopt DM will depend on how the program is designed and on the level of involvement a practice requires. It may be difficult for a national program to influence care at the practice level. Doctors may be reluctant to incur any costs related to a redesign of services (Leeman and Mark, 2006).

We assume that for DM programs to be optimally successful they must integrate with the medical care the patients already receive.

It remains unclear how well disease management programs can integrate with physicians' care of patients with chronic disease.

The specifics of a given DM program determine the challenges with its implementation. The feasibility will also be influenced by whether a program is developed from scratch or whether an existing DM program is used (Harvey and DePue, 1997). Differentiating start-up costs from steady-state costs can be difficult, as can the planning for future capacity.

Regarding the feasibility of integrating DM with physician practices, a roundtable by the Disease Management Association of America (2005) found that physicians cite a number of barriers to using DM programs: the absence of financial incentives, the degree to which DM programs can be time consuming or disrupt office workflow, the lack of information exchange between DM programs and physician records, and that DM programs can be viewed as an extension of payers rather than of a physician's own practice. Further, physicians expressed concern that an individual patient centered approach to DM contrasted with a population approach, which refers to an intervention that is directed at a group of individuals (e.g., all of the people who work for a particular company) and generally emphasizes engaging in healthy behaviors and following preventive care guidelines. For example, a population approach might involve identifying all the individuals enrolled in a particular health plan who have a particular medical condition and providing an intervention targeted at all of them (e.g., a class to help with control of particular risk factors).

  1. A population approach to disease management refers to an intervention that is directed at a group of individuals (e.g., all of the people who work for a particular company) and generally emphasizes engaging in healthy behaviors and following preventive care guidelines. For example, it might involve identifying all the individuals enrolled in a particular health plan who have a particular medical condition and providing an intervention targeted at all of them, e.g., a class to help with control of particular risk factors.

References

Disease Management Association of America (DMAA), Physician Involvement in Disease Management: Roundtable Discussion, 7th Annual Disease Management Leadership Forum, San Diego, Calif., October 16, 2005. As of November 6, 2008: http://www.dmaa.org/pdf/DMAA_Physician_Roundtable.pdf

Harvey N, DePue DM, "Disease Management: Program Design, Development and Implementation," Healthcare Financial Management, June 1, 1997.

Leeman J, Mark B, "The Chronic Care Model Versus Disease Management Programs: A Transaction Cost Analysis Approach," Health Care Management Review, Vol. 31, No. 1, January/March 2006, pp. 18-25.

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