The Basics

This standard sets forth very specific requirements of your DTM program's periodic program evaluation process.  This process must be a detailed cost/benefit analysis.

First, the evaluation process must address projected clinical and health-related outcomes using, at least, the following performance measures:

• previous clinical and health-related outcomes;
• clinical and health-related outcomes for current purchasers;
• projected clinical outcomes for current or prospective purchasers; and
• how lab values and health screening data will be used in conjunction with self-reported data.

Second, the evaluation process must assess the financial benefits of the program using, at least, the following performance measures:

• previous financial outcomes;
• previous financial outcomes for current purchaser; and
• projected financial outcomes for new or prospective purchasers.

Third, the program evaluation must assess the impact of the program using other outcomes of the program in addition to those clinical and financial outcomes described above.

Management Tips

Your program evaluation documentation should be very explicit in outlining the clinical, financial, and other outcomes used.  As these measures relate to individual consumers, your program evaluation should involve a baseline assessment for those consumers against which you can compare subsequent health outcomes.  Possible metrics that you can use regarding financial outcomes could include claim costs, costs extrapolated from risk categories and health metrics, or Quality Adjusted Life Years, or the cost of employee recruitment and retention.

URAC Accreditation Tips

The 13 elements of the standard range from Leading Indicator to Mandatory.

For the desktop review, you should submit your evaluation methodology, which should include a detailed description of your outcome measurements.  In addition, you should submit sample quality management committee meeting minutes demonstrating that the committee has evaluated the outcomes.

The on-site reviewer will interview staff members about the outcomes measurement processes for the program evaluation.  In addition, the reviewer will want to see reports to clients or purchasers, meeting minutes, and even marketing materials for potential clients.