The goal of disease management programs is to provide better care to patients at lower costs to payers. Utilization review was the tool introduced by managed care organizations to assess whether specific components of care met the test of medical necessity and therefore reimbursibility. This approach has been widely criticized as being cost-based, wasteful, reactive, and lacking in coordination and continuity. Unlike utilization review programs that focus on specific components of care, disease management programs focus on systems and are informed by an understanding of the natural course of a disease.
Behavioral care is the glue that binds all disease management efforts together.
To be sure, physician, administrative, and IS cooperation is essential in order to implement a successful DM program, one that actually improves outcomes and controls costs. But it is the patient who has the most profound impact on clinical outcomes. It is his or her actions that will determine whether optimal outcomes are achieved. Disease management programs expand the focus of management of medical conditions to a more comprehensive consideration of quality and outcomes. Behavioral Disease Management Behavioral disease management starts with the recognition that behavioral health problems are commonly occurring disorders that are treated in primary care and specialty mental health care and specialty medical care settings.