The Basics

This standard establishes requirements for how your DM program should measure condition-specific outcomes.  The measurement methodology must be valid, spelling out:

• from where the data comes (i.e., the patient, providers, claims, UM, surveys, and other sources)
• the time frame for the baseline measurement,
• the time frame for the outcomes analysis (beginning and end of analysis period),
• the formula for the calculation of the outcomes measurement,
• how external factors (e.g., participation of the patient in multiple DM programs) will be addressed in the measurement calculation, and
• how often the program will report outcomes (at least annually).

It may be that your program reports different outcomes for different clients, so make sure you’re familiar with all the reporting requirements.

Management Tips

A typical outcome measurement has the number of people with a successful outcome in the numerator of a fraction that has the total number of people with the condition in the denominator of that fraction.

The most challenging element of this standard is that which requires adjustment for external factors.  URAC requires the following factors to be addressed in your outcomes calculations:

• Population inclusion criteria;
• Co-morbidities that make the patient eligible for more than one DM program;
• Patients participating in more than one disease management program because of co-morbidities;
• Large changes in participants due to occurrences like acquiring or losing a client;
• Costs unrelated to the condition or common co-morbidities;
• Claims run-out;
• Inflation; and
• How to adjust for variation between patients in how long they are in the program.

Make sure all these elements are documented, both in P&Ps and in the measurement process.

URAC Accreditation Tips

Each of the five elements in this standard carries a weight of 3.

At the desktop review phase of the accreditation process, you should submit documentation that describes your methodology for both measurement and reporting.  In addition, submit sample reports with as much background data as possible.   If your program retains an outside auditor of your methodology, submit a report from the auditor.

During the onsite review, be prepared to give a presentation on your outcomes measurements using PowerPoint and handouts.  The reviewer will examine outcomes reports, as well.  Finally, the reviewer will interview your QM analysts, asking such questions as:

• Where do you get the data for your outcomes measurements?
• What are the time frames for analysis?
• What is the formula you use to calculate outcomes?
• How do you adjust for (1) participation in multiple programs, (2) External factors such as comorbidities, trauma, or pregnancy, (3) Inflation? (4) Varying lengths of participation in the program?