The study
Issues and Innovations in Care
Management for Medicaid
Enrollees with Multiple Chronic
Conditions
Presented at AcademyHealth
Annual Research Meeting
June 25, 2006
„
Funding: Kaiser Permanente Community
Benefit
„
Conducted by: Center for Health Care
Strategies, Project Director - Melanie Bella
„
Overview: Review of literature and expert
interviews to identify issues and innovations for
addressing the needs of Medicaid enrollees with
multiple chronic conditions
Claudia H. Williams, AZA Consulting
cwilliams@azaconsult.com
1
Spending and complexity of care
increases with number of conditions
Study context
„
Almost two thirds of adult Medicaid enrollees
have a chronic condition
„
46 percent of Medicaid enrollees with one
chronic condition have another
„
As number of conditions increases, so does the
cost and complexity of care
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We lack measures and protocols that
take into account multiple conditions
Three main study findings
„
We lack measures and protocols that take into
account multiple conditions
„
Traditional disease management (DM) models
don’t meet needs of clients with multiple chronic
conditions
„
4
Issues
„
The interplay of multiple health issues creates
an effect of “cascading conditions” - each
condition needs to be examined in light of others
„
We lack measures, protocols and guidelines that
take this into account
„
Existing guidelines—the foundation of disease
management—are disease-specific
Chronic care initiatives are not patient-centered
•
5
Based on evidence base from randomized trials that
often screened out people with multiple conditions
6
1
We lack measures and protocols that
take into account multiple conditions
Traditional DM models don’t meet needs of
clients with multiple chronic conditions
Solutions
Issues
„
Guidelines/measures for disease clusters
•
•
•
Asthma and COPD
Diabetes, cardiovascular disease and depression
Cross-cutting : depression, substance abuse, chronic
pain
„
Integrate the expertise of siloed specialty groups
to develop new guidelines
„
New identification strategies - disease clusters
and full risk assessment
„
Traditional DM layers a focused behavioral
intervention onto the existing care process
„
This is insufficient for Medicaid enrollees with
multiple conditions
„
They lack a system to help them organize,
coordinate, make sense of and navigate Health
care
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8
Strategies vary based on needs of
client
Traditional DM models don’t meet needs of
clients with multiple chronic conditions
Solutions
„
Develop “organizing entity”
•
•
„
Helps consumers navigate health care system
Provides infrastructure, tools, data and incentives to
organize chronic care
Several alternative models
•
•
•
North Carolina’s Regional Physician Networks
Cambridge Health Alliance
Bellingham Washington
9
10
Chronic care initiatives are not patientcentered
Chronic care initiatives are not patientcentered
Issues
Solutions
„
A more active and engaged consumer is at the
heart of chronic care concepts
„
Many initiatives play lip service to this concept,
but are not truly patient-centered and
collaborative
„
•
Care management approach that start with a
single disease and work “upstream” and
“downstream”
„
Direction (not just input) from consumer on
composition of care team, improvement goals
•
What does being patient-centered mean for
consumers with multiple chronic conditions?
•
„
„
Addressing multiple and not single conditions
Patient voice and perspective drives the approach
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Whatcom County patient health record
Home visits integrated with other modes of care
management
12
2
Future considerations
Medicaid Value Program Teams
Team
„
Too little is known about the population
„
There is critical need to think through financing
„
„
We should pursue true integration of behavioral and
physical health
DRA: Co-morbidites add to complexity of aligning
consumer incentives and behavior
Study Design
Calculating ROI
CareOregon
Expansion of complex care management for highest risk and most complex members (ACG>0.5).
Project Description
treatment-control
y
Comprehensive
NeuroScience, Inc.
Implement the Medical Risk Management (MRM) program for consumers with schizophrenia and comorbidities. MRM program will identify patients at risk of adverse health outcomes, summarize and
communicate recent health care service use to all involved provid
treatment-control
y
treatment-comparison
no
Case manager contacts
Total medical costs
Nursing home days
SA/ MH treatment visits
Total medical costs
Hospital readmissions
D.C. Dept. of Health, Test and validate the clinical and economic outcomes of the Medical House Call Program (MHCP), a
Medical Assistance Medicaid waiver program that coordinates all home, hospital, and community-based care for elderly
consumers.
Administration
Critical questions about how to assemble and pay
“overarching entities”
•
How create these? How pay for them? How measure their
success?
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Inpatient, outpatient, pharmacy
costs
ER admits
Inpatient admits
Johns Hopkins
HealthCare LLC
Expansion of existing care management program treating Medicaid consumers with chronic illness(es) and
treatment-comparison
a co-occurring mental health and/or substance abuse disorder.
y
Managed Health
Services, Inc
Evaluate the validity of predictive modeling and health risk assessment screening for identification and
enrollment of high risk SSI consumers into case management.
logistic regression
model
no
Case management placement
Comparison of predictive ability of the
two tools
McKesson Health
Solutions
Assess the effectiveness of providing diabetes group education to aged, blind and disabled consumers in
the New Hampshire and Oregon Medicaid programs.
treatment-control
y
ER admits
Inpatient admits
Insulin and oral hypoglycemic use
Cardiac Inpatient admits
Implement the Most Valued Partner (MVP) Program. The MVP program features a Health Navigator as
Memorial Healthcare
part of the disease management team to organize care and develop a care plan, utilizing a patientSystem
centered approach
„
Sample of Project Measures
Average PMPM
ER admits
Unplanned hospital admits
Health Unity Index Score
treatment-control
no
Functional status
Avoidable inpatient admissions
Referral compliance
Partnership Health
Plan of California
Improve screening and care management for diabetics with hypertension, cardiovascular disease, and/or
depression using concepts from Kaiser PermanenteÕs Prevent Heart Attacks and Strokes Everyday
(PHASE) program.
treatment-comparison
y
Controlled HbA1c/ LDL/ BP
Depression screening
Appropriate meds per PHASE
University of
California at San
Diego
Expand Project Dulce, (existing diabetes management program in San Diego County community clinics),
to include care management for consumers with diabetes and depression using the Improving MoodPromoting Access to Collaborative Treatment (IMPACT) model.
treatment-control
y
Washington State
Dept. of Social and
Health Services
Launch the Washington Medicaid Integration Partnership (WMIP). The WMIP integrates primary care,
mental health, and substance abuse services, long-term care, and disease management for the target
population using intensive and ongoing case management serv
treatment-comparison
y
Outpatient utilization and cost
ER admits
MH visits
QOL
ER admits
Inpatient admits
MH/ SA treatment visits
Care coordination contacts
14
For additional information - please see
full report at www.chcs.org
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