Can disease management work in Medicaid managed care?
With many commercial managed care companies using disease management programs to help contain costs, Florida’s experience in trying to use disease management in a Medicaid managed care context could help other states considering such a move.
In 1996, the Florida legislature and the state’s Agency for Health Care Administration began planning for the design and implementation of a chronic disease management program to overlay MediPass, the state’s primary care case management program. Florida’s chronic disease management program has been operational since May 1999, using contracts with seven vendors for five specific chronic illnesses:
• HIV/AIDS;
• diabetes;
• hemophilia;
• congestive heart failure;
• end stage renal disease.
Plans are under way to contract with vendors to provide services for cancer, hypertension, and sickle cell anemia.
While there is not enough experience with the program to evaluate its impact on health outcomes, the Center for Health Care Strategies (CHCS) in Lawrenceville, NJ, decided to examine the program in terms of key operational and policy issues that Florida dealt with in its planning and early implementation. Nikki Highsmith, an analyst with CHCS, tells State Health Watch there are some lessons to be learned from Florida’s experience.
One problem in Florida was there were not enough linkages built between the vendor disease management organizations (DMO) and provider organizations. "[Administrators] essentially built two separate programs even though they were with the same people," Ms. Highsmith says. "People had to learn to navigate through the two programs, and that made it hard for both beneficiaries and providers. Some vendors did well in connecting with physicians, but some did not."
Because physician participation is voluntary, the DMOs are required to contact a member’s primary care physician (PCP) to secure his or her participation and to discuss these issues:
1. the role of the DMO regarding education and information about the relevant clinical guidelines and standards of care;
2. availability of case management services to members and providers;
3. requirement of the PCP to provide the DMO with access to encounter-level data/medical records in an effort to monitor and evaluate service delivery and program effectiveness. The DMO is neither contractually authorized nor responsible for physician credentialing, compliance monitoring, or utilization management.
Another potential problem observed by CHCS is that the Florida disease management program was structured to be voluntary for both beneficiaries and providers. "States should consider mandatory enrollment in chronic disease management programs," Ms. Highsmith’s research report says. "Florida’s program is voluntary. Many other states’ Medicaid managed care programs, however, have shown that mandatory enrollment achieves higher enrollment volume [needed to achieve economies of scale] and controls for selection bias."
Florida’s legislature mandated establishment of the nation’s first and only statewide Medicaid chronic disease management program after receiving reports that it could reduce the higher cost services such patients often require, while improving their quality of life. In anticipation of cost savings to be reaped from the program, the legislature reduced the Medicaid budget for FY 1997-98 by $4.17 million, with an additional $39.4 million decrease in FY 1998-99, and a decrease of $20 million in FY 1999-2000. The pressure for early cost savings to offset the reduced appropriations undoubtedly has had an impact on the program.
As operated in Florida, the program has five elements:
• outreach and stratification;
• reimbursement and payment methodology;
• quality assurance and outcomes;
• provider roles and participation;
• care management.
Identifying participants
Recipients with target diagnoses are identified monthly through the state agency’s retrospective claims analysis and are automatically assigned to a DMO. The vendor must contact the beneficiary to confirm eligibility for the program, complete a new member assessment, and solicit participation of the patient’s PCP. The patient has 30 days in which to opt out of the disease management effort. CHCS says that while the assign in/opt out process has produced more enrollees than would have been expected in a purely voluntary program, it requires the vendors to contact individual members, and that can be a problem because many beneficiary telephone numbers are missing or incorrect. Recipients also can self-refer to the program.
Timely and accurate access to both clinical and utilization data by disease management organizations and physician leaders is critical to success of any disease management program, and that has been an issue in Florida, according to the CHCS study. "In Florida, the DMO is not responsible for authorizing services, nor is it responsible for medical or pharmacy claims payment. This eliminates a rich [though not complete] data source from which to measure utilization variations and identify opportunities for intervention.
"The second and probably more complex side of the data equation relates to the accessibility of patient-specific clinical data contained in the patient medical record. The patient medical record is the data warehouse’ — the one central data source containing physician orders, ancillary and diagnostic testing results, specialist consultation findings, and other medical history. DMOs must be able to access these data to truly manage patient care. For example, the DMO needs to identify, track, and evaluate the combination drug therapy regimens for HIV patients, measure the effectiveness and patient compliance with the results of viral load testing CD4 counts, and at the same time, promote and track other prophylactic services and treatments. . . . The DMOs are challenged to create accurate and efficient systems for collecting these patient data, whether through on-site medical record audits, clinical encounter level data reports, or a combination thereof. Absent highly technical and sophisticated systems for data exchange, integration of clinical data remains a manual, labor-intensive process, and one that is nonreimbursable."
Ms. Highsmith says that because many patients have multiple chronic conditions, they can be in more than one disease management program with more than one DMO. Having different vendors for each diagnostic category can make coordination of care difficult, she reports.
One state that has integrated a disease management program with its primary care case management program is North Carolina, whose Access program has been working successfully in rural areas. Michael Keogh, a program consultant, tells State Health Watch that the state has been involved with PCP case management since 1991, and that effort has evolved into the Access 2 and Access 3 programs in select communities and counties.
The programs are an effort to improve access and quality and control costs through a collaborative joint governance process that allows all factions to be at the table. Disease management components focus on asthma, diabetes, otitis media, and other chronic needs, Mr. Keogh says. The community-based case management program uses registered nurses to work with high-risk patients who have been identified through an assessment form. State funds are used to support the local-level disease management activities. Under the theory that "local people know local needs best," the state pays $2.50 per member per month for disease management and case management efforts, allowing the local organizations to hire local people to do the disease management work using protocols provided by national organizations.
Reducing ED visits
Mr. Keogh says quarterly chart reviews and analysis of emergency department (ED) visits have indicated the program has been successful in increasing the use of asthma drugs, for instance, and reducing unnecessary ED visits.
Mr. Keogh’s advice to other states interested in emulating North Carolina’s success is to recognize that "a community development model works." Rural residents don’t want to lose control over the health care system in their communities, and the Access program helps them maintain control, he adds.
[Contact Ms. Highsmith at (609) 895-8101 and Mr. Keogh at (919) 733-2040.]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content