Managing and Evaluating Healthcare Intervention Programs

By Ian G. Duncan · ACTEX Learning · 2014

A textbook on the financial management and evaluation of healthcare intervention programs, which its publisher describes as the first textbook devoted to the subject. The second edition is in four parts: an introduction to care management interventions, actuarial issues in care management interventions, practical applications, and wellness, integrated programs and other new developments.

On the syllabus

Exam GH-301 — Disease Management; Ch. 3: Care Management Programs and Interventions (2a); Ch. 8: Understanding the Economics of Care Management Programs (2b); Ch. 9: Applying the Economic Model: The Example of Opportunity Analysis (2b); Ch. 11: The Use of Propensity Scoring in Program Evaluation (2b); Ch. 12: An Actuarial Method for Evaluating Care Management Outcomes, excluding Appendix 12.2-12.3 (2c); Ch. 13: Understanding Patient Risk and Its Impact on Chronic and Non-Chronic Member Trends (2d); Ch. 16: Testing Actuarial Methods for Evaluating Disease Management Savings Outcomes, excluding Appendices (2b).

Introduction to the Second Edition

Introduction to the First Edition

Acknowledgments

Part I An Introduction to Care Management Interventions

1 Introduction

1.1 A Guide to the Contents of This Book
1.2 The State of the Union
1.3 What Has Changed?
1.4 Where to From Here?
1.5 What Have We Learned From Our Research
1.6 A Change in Emphasis for Actuaries?

2 Clinical Background

2.1 Introduction
2.2 Diseases of Specific Body Systems
2.3 Financial Implications of Disease
2.4 Summary

3 Care Management Programs and Interventions

3.1 Introduction
3.2 Pre-Authorization
3.3 Concurrent Review
3.4 Case Management
3.5 Demand Management
3.6 Disease Management
3.7 Specialty Case Management
3.8 Population Health Management
3.9 Care Coordination and Other Intervention Model Enhancements
3.10 The Patient Centered Medical Home and Pay for Performance
3.11 Accountable Care Organizations
3.12 Non-Traditional Providers and Care Settings
3.13 Gaps in Care and Quality Improvement Programs
3.14 Telemedicine, Telehealth, and Automated Monitoring
3.15 Bundled Payment Initiatives
3.16 Conclusion

4 Actuarial Issues in Care Management Evaluations

4.1 Introduction
4.2 Measurement Principles
4.3 Study Design Issues
4.4 Risk Factors
4.5 Conclusions
Appendix 4.1 Causality

5 Estimating Savings, Utilization Rate Changes and Return on Investment: A Selective Review of the Literature on Program Evaluation

5.1 Introduction
5.2 Searching the Health Care Literature
5.3 Summary of Results: Original Study
5.4 Current Study
5.5 Conclusion

6 The Use of the Value Chain in Care Management Program Planning

6.1 Introduction
6.2 The CM Value Chain – Overview
6.3 Components for Establishing Programs
6.4 The Role of Value Chain Components in Program Design and Assessment
6.5 Managing the Intervention Program using the Value Chain

7 Clinical Quality and its Measurement

7.1 Introduction
7.2 Layout of This Chapter
7.3 The Challenge of Data Analysis for Quality Measurement
7.4 Quality Organizations and Initiatives
7.5 Categories of Measures
7.6 Measurement Process
7.7 Measurement Construction
7.8 Consumer Assessment of Quality (HCAHPS)
7.9 Application of Measures in Quality Improvement Initiatives
7.10 Conclusion
Appendix 7.1 Summary of Quality Organizations and Measures
Appendix 7.2 CMS Performance Incentives
Appendix 7.3 Chronic Condition Clinical Performance Measures to be Tracked
Appendix 7.4 ACO Quality Performance Measures Required by CMS
Appendix 7.5 Medicare Part C & D and Medicare PDP Quality Performance Measures Required by CMS
Appendix 7.6 CMS HER Meaningful Use Measures (Stage 1)
Appendix 7.7 Surgical Care Improvement Program (SCIP)
Appendix 7.8 Consumer Assessment of Quality (HCAHPS)

Part II Actuarial Issues in Care Management Interventions

8 Understanding the Economics of Care Management Programs

8.1 Introduction
8.2 What is the Appropriate Financial Statistic to Measure?
8.3 The Risk Management Economic Model
8.4 Designing a Program
8.5 Components of the Risk Management Economic Model
8.6 Conclusion
Appendix 8.1 Calculating Return on Investment

9 Applying the Economic Model: The Example of Opportunity Analysis

9.1 Introduction
9.2 What is Opportunity Analysis?
9.3 Member Stratification for Opportunity Analysis
9.4 Designing a Program
9.5 Implementing a Program
9.6 The Value of Opportunity Analysis
9.7 Conclusion

10 Measuring Care Management Savings Outcomes

10.1 Introduction
10.2 Evaluating a Savings Calculation
10.3 Principles of Measurement Design: What Constitutes a Valid Methodology?
10.4 Study Designs for DM: A Summary
10.5 The Problem of Multiple Programs
10.6 Conclusion

11 The Use of Propensity Scoring in Program Evaluation

11.1 Introduction
11.2 What is a Propensity Score?
11.3 History of Propensity Score Matching
11.4 General Approach to Propensity Score Matching
11.5 Propensity Scores and Risk Adjustment
11.6 Application of Propensity Score Matching to Diabetes Education
11.7 Hypothesis
11.8 Methods
11.9 Results
11.10 Conclusions

12 An Actuarial Method for Evaluating Care Management Outcomes

12.1 Introduction
12.2 The Actuarially-Adjusted Historical Control Methodology
12.3 Practical Application of the Actuarially-Adjusted Historical Control Methodology
12.4 Exposure
12.5 Time Periods
12.6 Chronic Members and Chronic Prevalence
12.7 Results and Use
12.8 Conclusion
Appendix 12.1 Members Excluded from Measurement
Appendix 12.2 Example of Claims Exclusion Criteria
Appendix 12.3 An Example of Member Classification over Time

13 Understanding Patient Risk and Its Impact on Chronic and Non-Chronic Member Trends

13.1 Introduction
13.2 Transition States and Their Effect on Equivalence and Trend
13.3 Equivalence, Transition states, and Trend
13.4 Practical Applications
13.5 Results
13.6 Applicability to Other Populations
13.7 Conclusion

14 Random Fluctuations and Validity in Measuring Disease Management Effectiveness for Small Populations

14.1 Introduction
14.2 Methods
14.3 Trends and Disease Management Savings Measurement
14.4 The Base Measurement Method – Effect of Using Group-Specific Trend
14.5 Alternate Measurement Method – Population Trend
14.6 Alternate Measurement Method – Using Truncation to Stabilize Measurement
14.7 Alternate Measurement Method – Utilization Measure
14.8 Minimum Sample Sizes for Specific Diseases
14.9 Practical Applications in Small Populations
14.10 Limitations
14.11 Conclusions
Appendix 14.1 Criteria used to Classify Members into Chronic Categories

Part III Practical Applications

15 A Comparative Analysis of Chronic and Non-Chronic Insured Commercial Membership Cost Trends

15.1 Introduction
15.2 Background
15.3 Population and Methods
15.4 Results
15.5 Discussion
15.6 Limitations
15.7 Conclusions and Implications for Disease Management Purchasers
Appendix 15.1 Relationship Between Overall Trends and Trends of Sub-Groups

16 Testing Actuarial Methods for Evaluating Disease Management Savings Outcomes

16.1 Introduction
16.2 Background
16.3 Methods
16.4 Results
16.5 Commercial HMO/POS Savings Calculation
16.6 Discussion
16.7 Conclusions
Appendix 16.1 Chronic Identification Criteria
Appendix 16.2 Check List of Issues/Assumptions for Conducting or Evaluating a Study

Part IV Wellness, Integrated Programs and Other New Developments in Care Management Programs

17 Introduction to Wellness and Integrated Programs

17.1 Healthcare Expenditures
17.2 Wellness, Health Promotion, and Disease Prevention
17.3 Workplace Health
17.4 Prevalence of Workplace Wellness Programs
17.5 Health Risk and Risk Status
17.6 Successful Wellness Programs
17.7 Core Components of a Workplace Wellness Program
17.8 Absenteeism, Presenteeism, and Productivity
17.9 Integrated Programs
17.10 Recent Developments in Wellness Programs
17.11 Conclusion

18 Evaluation of Worksite Wellness Programs: Selective Review of the Literature

18.1 Introduction
18.2 Workplace Wellness Programs – The Literature
18.3 Health Risk and Associated Medical Care Expenditure
18.4 Financial Impact of Wellness Programs
18.5 Risk Transition
18.6 Health Risk and Productivity
18.7 Health Related Productivity – Estimating Financial Impact
18.8 Discussion of the Evidence
18.9 Conclusion

19 The Relationship Between Health Risk Factors and Health Care Claims Cost in Program Design and Evaluation

19.1 Introduction
19.2 PART 1: Model Development
19.3 Use of the Model for Intervention Program Planning
19.4 Using the Model for Savings Estimation
19.5 Application to Other Programs and Situations
Appendix 19.1 Risk Scores and Their Use in Our Models

Bibliography

Index

Sources

Managing and Evaluating Healthcare Intervention Programs, 2nd Edition, sample pages (ACTEX Learning) — the book itself: copyright page (2008, 2014) and the table of contents by part, chapter and section (read from the PDF; sha256 8c518c6ebe27461e…)
Managing and Evaluating Healthcare Intervention Programs (ACTEX Learning) — the publisher's record: author, edition, the printed ISBN (978-1-62542-112-8; the sample's copyright page prints the digital edition's 978-1-62542-816-5) and the description for the lead
GH-301 Syllabus, Nov 2026/Mar 2027/Jul 2027 (SOA) — the citation (2nd Edition, 2014) and the chapters and outcomes assigned