[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]
EVALUATING COORDINATION OF CARE IN MEDICAID: IMPROVING QUALITY AND
CLINICAL OUTCOMES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
OCTOBER 15, 2003
__________
Serial No. 108-57
__________
Printed for the use of the Committee on Energy and Commerce
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
__________
89-962 U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 2003
----------------------------------------------------------------------------
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512�091800
Fax: (202) 512�092250 Mail: Stop SSOP, Washington, DC 20402�090001
COMMITTEE ON ENERGY AND COMMERCE
W.J. ``BILLY'' TAUZIN, Louisiana, Chairman
MICHAEL BILIRAKIS, Florida JOHN D. DINGELL, Michigan
JOE BARTON, Texas Ranking Member
FRED UPTON, Michigan HENRY A. WAXMAN, California
CLIFF STEARNS, Florida EDWARD J. MARKEY, Massachusetts
PAUL E. GILLMOR, Ohio RALPH M. HALL, Texas
JAMES C. GREENWOOD, Pennsylvania RICK BOUCHER, Virginia
CHRISTOPHER COX, California EDOLPHUS TOWNS, New York
NATHAN DEAL, Georgia FRANK PALLONE, Jr., New Jersey
RICHARD BURR, North Carolina SHERROD BROWN, Ohio
Vice Chairman BART GORDON, Tennessee
ED WHITFIELD, Kentucky PETER DEUTSCH, Florida
CHARLIE NORWOOD, Georgia BOBBY L. RUSH, Illinois
BARBARA CUBIN, Wyoming ANNA G. ESHOO, California
JOHN SHIMKUS, Illinois BART STUPAK, Michigan
HEATHER WILSON, New Mexico ELIOT L. ENGEL, New York
JOHN B. SHADEGG, Arizona ALBERT R. WYNN, Maryland
CHARLES W. ``CHIP'' PICKERING, GENE GREEN, Texas
Mississippi KAREN McCARTHY, Missouri
VITO FOSSELLA, New York TED STRICKLAND, Ohio
ROY BLUNT, Missouri DIANA DeGETTE, Colorado
STEVE BUYER, Indiana LOIS CAPPS, California
GEORGE RADANOVICH, California MICHAEL F. DOYLE, Pennsylvania
CHARLES F. BASS, New Hampshire CHRISTOPHER JOHN, Louisiana
JOSEPH R. PITTS, Pennsylvania JIM DAVIS, Florida
MARY BONO, California THOMAS H. ALLEN, Maine
GREG WALDEN, Oregon JANICE D. SCHAKOWSKY, Illinois
LEE TERRY, Nebraska HILDA L. SOLIS, California
ERNIE FLETCHER, Kentucky
MIKE FERGUSON, New Jersey
MIKE ROGERS, Michigan
DARRELL E. ISSA, California
C.L. ``BUTCH'' OTTER, Idaho
Dan R. Brouillette, Staff Director
James D. Barnette, General Counsel
Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
______
Subcommittee on Health
MICHAEL BILIRAKIS, Florida, Chairman
JOE BARTON, Texas SHERROD BROWN, Ohio
FRED UPTON, Michigan Ranking Member
JAMES C. GREENWOOD, Pennsylvania HENRY A. WAXMAN, California
NATHAN DEAL, Georgia RALPH M. HALL, Texas
RICHARD BURR, North Carolina EDOLPHUS TOWNS, New York
ED WHITFIELD, Kentucky FRANK PALLONE, Jr., New Jersey
CHARLIE NORWOOD, Georgia ANNA G. ESHOO, California
Vice Chairman BART STUPAK, Michigan
BARBARA CUBIN, Wyoming ELIOT L. ENGEL, New York
HEATHER WILSON, New Mexico GENE GREEN, Texas
JOHN B. SHADEGG, Arizona TED STRICKLAND, Ohio
CHARLES W. ``CHIP'' PICKERING, LOIS CAPPS, California
Mississippi BART GORDON, Tennessee
STEVE BUYER, Indiana DIANA DeGETTE, Colorado
JOSEPH R. PITTS, Pennsylvania CHRISTOPHER JOHN, Louisiana
ERNIE FLETCHER, Kentucky JOHN D. DINGELL, Michigan,
MIKE FERGUSON, New Jersey (Ex Officio)
MIKE ROGERS, Michigan
W.J. ``BILLY'' TAUZIN, Louisiana
(Ex Officio)
(ii)
C O N T E N T S
__________
Page
Testimony of:
Bella, Melanie M., Assistant Secretary, Office of Medicaid
Policy and Planning, State of Indiana...................... 33
Hilferty, Daniel J., President and CEO, Keystone Mercy Health
Plan of Philadelphia, on behalf of the American Association
of Health Plans............................................ 18
Medows, Rhonda, Secretary, Florida Agency for Health Care
Administration............................................. 24
Selecky, Christobel E., Chief Executive Officer, Lifemasters
Support Selfcare, Inc., on behalf of the Disease Management
Association of America..................................... 7
Simms, Jeffrey, Assistant Director, North Carolina Division
of Medical Assistance...................................... 29
Material submitted for the record by:
American Dental Association, prepared statement of........... 53
McAndrews, Lawrence A., President and CEO, National
Association of Children's Hospitals, prepared statement of. 55
Medows, Rhonda, Secretary, Florida Agency for Health Care
Administration, follow-up to written testimony............. 67
National Association of Chain Drug Stores, prepared statement
of......................................................... 57
National Association of Community Health Centers, prepared
statement of............................................... 59
Wadhwa, Sandeep, Vice President, Medical Management Services,
McKesson Health Solutions, McKesson Corporation, prepared
statement of............................................... 64
(iii)
EVALUATING COORDINATION OF CARE IN MEDICAID: IMPROVING QUALITY AND
CLINICAL OUTCOMES
----------
WEDNESDAY, OCTOBER 15, 2003
House of Representatives,
Committee on Energy and Commerce,
Subcommittee on Health,
Washington, DC.
The subcommittee met, pursuant to notice, at 10 a.m., in
room 2123, Rayburn House Office Building, Hon. Michael
Bilirakis (chairman) presiding.
Members present: Representatives Bilirakis, Wilson, Brown,
and Green.
Staff present: Patrick Morrisey, deputy staff director,
Chuck Clapton, majority counsel: Jeremy Allen, health policy
coordinator; Eugenia Edwards, legislative clerk; David Nelson,
minority counsel; Bridgett Taylor, minority professional staff
member; Purvee Kempf, minority professional staff member; and
Jessica McNiece, minority staff assistant.
Mr. Bilirakis. Good morning. I call this hearing of the
Health Subcommittee to order. If you are wondering what we were
just discussing up here, the very significant issue of the Cubs
game last night, and to the couple of young people there who
tried to catch that foul ball and probably will be ostracized
the rest of their lives from Chicago. I would have to move if I
lived there.
Anyhow, I would like to thank our witness for taking the
time to join us and provide their perspectives of strategies
for improving the health of Medicaid patients to enhance care
and coordination activities.
As I pointed out during last week's subcommittee hearing on
challenges facing the Medicaid program in the 21st century, a
comprehensive review of Medicaid should reveal a number of
opportunities underlined for improving this program. In my
opinion, learning more about the innovative strategies States
are adopting to improve patient care is one of those
opportunities. I feel that this is an especially critical area,
because as we discussed last week, Medicaid payments for
elderly, blind, and disabled beneficiaries who represent 27
percent of the total Medicaid population account for 73 percent
of total payments.
Obviously, these beneficiaries who are more likely to
suffer from one or more chronic illnesses have the most to gain
from effective coordination of care programs. Additionally, the
Medicaid program itself could realize substantial savings as
well. As we will discuss today, States have used a number of
different strategies, most notably disease management to meet
this goal. My own State of Florida, for example, has partnered
with several entities to better manage the chronic conditions
that we know make up such a large part of Medicare spending--of
Medicaid spending, and I am pleased that Dr. Rhonda Medows, the
Secretary of Florida's Agency for Health Care Administration,
was able to join us this morning.
Welcome, Doctor, and I know that we are all looking forward
to hearing more about Florida successes. Many States are also
beginning to enroll more of their Medicaid beneficiaries in
managed care plans. There is evidence that beneficiary outcomes
are improving under the managed care model which emphasizes
coordinating care, preventive benefits, disease management
services for chronically ill patients and improving patient
outcomes. We will find out from you hopefully whether that is
the case.
And finally today, we will explore what kind of programs
States have adopted through their traditional fee-for-service
structure to help improve patient outcomes. Primary care, case
management programs have been implemented in a number of
States. We have a couple of State representatives with us today
to talk a little more about their ideas and how they have
worked at the State level. It is my hope that this survey of
coordination of care programs will help members of the
subcommittee learn more about what types of care coordination
strategies work best and how we can apply these lessons as we
continue to think about how we can get the most out of our
Federal investment and Medicaid.
I would like to, again, thank all of our witnesses for
joining us today, and we all look forward to your testimony and
am pleased now to yield to my friend from Ohio now, Mr. Brown,
for an opening statement.
Mr. Brown. Thank you, Mr. Chairman.
Thank you all, to all the witnesses who are joining us this
morning. I would like to start by commending Ms. Wilson, my
friend from New Mexico who has worked on behalf of the
committee to determine whether there are ways to maximize our
return from investment on Medicaid and especially appreciate
the work she has done.
To the extent that we can use information and coordination
and outreach to reduce the burden of disease we enhance
Medicaid's role in the public health system and potentially
squeeze more value out of the dollars we invest. It makes sense
to pursue these goals.
Looking at my own State of Ohio, disease management is one
of several tools the State's Medicaid program is using to
improve health and health care in that State; for example,
Medicaid--Ohio Medicaid--has initiated a large physician
profiling demonstration to learn more about variations in
clinical practice and make use of that information to refine
clinical outcomes.
Ohio's Medicaid's also working with the public health and
provider community to make sure children receive age-
appropriate immunizations and increase the number of high risk
children who receive screening for lead poisoning.
Ohio has also initiated several demonstration projects
aimed at improving the quality and cost effectiveness of care
for the aged, the aged, the blind, and disabled.
Public health outreach, disease management, and other tools
would be worthwhile, even if they didn't save money, but there
is every reason to believe that they can and they will, but I
have reservations about relying on Medicaid HMO's and private
disease management companies as a primary vehicle for
integrating coordination of care into Medicaid. Effective
disease management, like effective health care, hinges on
continuity. HMO's undoubtedly do some things well but providing
continuity of care is not one of them.
Some 2.4 million senior and disabled Americans have been
dumped from Medicare+Choice HMO's over the last 4 years. It
would be difficult to find a population more in need of care
coordination of continuity of care than Medicaid beneficiaries,
but disappearing coverage and disease management just simply do
not mix very well.
Over the last 4 years, three Ohio HMO's, for instance,
contracting with the Medicaid program, were shut down by the
Department of Insurance, leaving both beneficiaries and
providers in the lurch. To put those three failures into
context, there were currently six HMO's currently serving
Medicaid patients in my State. Three HMO failures is not a
minor problem. Medicaid and pullouts are certainly not unique
to Ohio, so continuity of care is an issue everywhere.
I also question whether we are actually setting the stage
for increased spending by paying private plans, whether they
are private HMO's or private disease management companies to do
what the Medicaid program itself could do.
To return to Medicaid plus Medicare+Choice, for example for
a moment, Medicare was supposed to save the program money. No
such luck.
Medicare+Choice plans have managed to inflate Federal
spending while deserting beneficiaries left and right. You
cannot begrudge HMO's their desire to maximize profits but you
can prevent them from earning those profits at the expense of
Medicare and the expense of Medicaid beneficiaries and American
taxpayers. That is not to say that partnering with private
companies is always a bad idea. It is just to say that
privatization is not invariably a good idea.
In the case of Medicare and Medicaid, if we overestimate
the ability of these companies to achieve efficiencies and
underestimate the length to come, they will go to maximize
profits. We will have no one but ourselves to blame when
disease management savings simply fail to materialize.
In the case of Medicare+Choice HMO's, we not only
overestimated their ability to achieve efficiencies, we allow
these plans to compromise core principles, like universality,
continuity, reliability. All this and higher Medicare
expenditures too, not exactly a bargain for beneficiaries or
for taxpayers.
When its profitability versus the public good,
profitability is going to win out, and when the choice is to
return the maximum number of dollars to State Medicaid programs
or return the maximum number of dollars to shareholders, the
shareholders are going to win in a private system.
We should consider all reasonable options when it comes to
making the most of the dollars we spend on Medicaid, but if
history is any guide, we should be aware of private sector
solutions that promises big gains at a small cost. As a woman
once wiser than I said, the nice thing about hitting your head
against the wall is it feels really good when you stop.
Thank you.
Mr. Bilirakis. The Chair thanks the gentleman, and I
appreciate Mr. Brown commenting on the work, task force work,
that Mrs. Wilson is undergoing on this issue, and I certainly
join in that accolade, and I will recognize her for an opening
statement.
Mrs. Wilson. Thank you, Mr. Chairman, and thank you for
holding this hearing today. It is the third in a series that
your subcommittee has held on Medicaid and ways that we can--I
hope it lays the foundation for looking at ways that we can
improve Medicaid for the people who depend upon it most.
In the first hearing that we had, we talked about consumer-
directed care, and the reality is under Medicaid, beneficiaries
have far fewer choices than most of the rest of us who have
health insurance provided by employers or private health
insurance. In giving people choices and the ability and the
knowledge to be able to manage their own care improves
satisfaction and improves people's health.
We also heard last week in testimony that Medicaid doesn't
do a very good job of collecting data on whether people's
health improves or not. Seems, though, we have all kinds of
information on how much money we spend, but almost no
information on whether anybody's life is better because we
spent it.
We lack the evidence to show what we can do to improve
people's health, and the reality is that Medicaid was really
set up for acute care. It was set up to pay claims and not to
prevent disease or to improve the quality of people's health
who have disease. It doesn't reward physicians for coordinating
care for people with chronic illness.
There are some States, about 21 of them, where beginning to
experiment with ways to manage chronic disease, because chronic
diseases represent about 60 percent of the cost of health care
in this country. Diseases like diabetes, heart disease, asthma
among children, depression and cancer, drive up health care
costs, and if we can manage those diseases to improve the
quality of health for those who are facing those diseases, we
will be much better off and much healthier as a country. But
Medicaid doesn't--is not set up to address those problems. It
shouldn't require a waiver from the rules to do what is right
in the first place, and we need to change Medicaid so that it
is not about following the payment slip and it is about
improving the health of those who depend upon it.
There are some tools we are going to hear about today that
I think are interesting and exciting, some States that decided
they were going to break the mold and ask for a waiver and beg
CMS to approve all of their paperwork, so that you can do some
innovative things to improve the health of the people who
depend on Medicaid. I am looking forward to hearing about the
results that you are seeing, but you shouldn't be the
exception. You should be the rule, and you shouldn't have to
say, ``Mother, may I,'' to get there.
I am particularly pleased to welcome Chris Selecky from the
LifeMasters here today. LifeMasters does some good work in the
State of New Mexico, and I look forward to hearing your
testimony and the testimony of all the witnesses we have here
today.
Thank you Mr. Chairman.
Mr. Bilirakis. I thank the gentlelady.
Mr. Green for an opening statement.
Mr. Green. Thank you, Mr. Chairman, and like my colleague,
I appreciate you holding these continued hearings on the
Medicare program, but particularly today with the care
coordination.It is an important issue, and I am glad we have
the opportunity to learn more about it.
Approximately 125 million Americans live with some form of
chronic disease, the most costly and preventable of all health
problems. According to the CDC, chronic diseases account for 75
percent of the $1 trillion spent on health care each year in
our country. They have an impact on almost every American
family for the premature death, long-term illness and
disability, loss of income and costly out-of-pocket expenses.
Chronic diseases are among the most prevalent costly and
preventable of health problems. By the year 2020, health care
expenditures for the chronic disease will actually reach $1
trillion, or 80 percent of health care costs. This is
especially problematic in the Medicaid program, as 30 percent
of Medicaid population suffers from these chronic diseases,
such as diabetes, hypertension, chronic obstructive pulmonary
disease, or cardiovascular disease.
The cost of treating chronic diseases account for 80
percent of the total Medicaid expenditures. Because Medicaid
patients often lack a primary care physician or rely on
emergency room for the treatment of these diseases, these
patients often lack access to the kind of preventative measures
that can help better control their chronic diseases, so
investigating ways to improve chronic disease management is
such an important topic, care coordination, disease management,
and primary case management and other programs have all sought
to improve outcomes for individuals as chronic diseases
throughout the same time reduces the cost in the program.
These programs aspire to improve day-to-day care for
conditions like diabetes and asthma, so that we can reduce the
number of hospital visits and acute episodes that often come
with these diseases are untreated. These programs not only make
financial sense but they also improve quality of life for the
beneficiaries who rely on them to improve their health.
I would much rather spend money preventing kidney failure
than have countless individuals with diabetes go on dialysis
each year, and I see that in my own district, but like every
other issue this committee considers, there is a disagreement
over different groups about how best to provide these services.
Some feel strongly that the private sector models are the best
route.
I would argue that the savings generated by real disease
management should be reinvested in the program, rather than
used to pay a percentage of corporate profits, and I think
these are fair questions and States are suffering some of their
worst budgeted crises in years, and Medicare dollars are
scarce. And again, I know from my own experience in Texas we
are having problems not only with Medicaid scarce dollars, but
also with our children's health care, where we lost almost
200,000 children for the budget shortfalls.
We should certainly do all we can to ensure that our
limited dollars are wisely spent, and Mr. Chairman, I look
forward to the testimony of our witnesses and I yield back my
time.
Mr. Bilirakis. I thank the gentleman.
[Additional statement submitted for the record follows:]
Prepared Statement of Hon. W.J. ``Billy'' Tauzin, Chairman, Committee
on Energy and Commerce
Thank you, Chairman Bilirakis, for holding this important hearing
today. I also want to thank all of our witnesses for their testimony,
which will provide valuable perspectives on current efforts to better
coordinate care for Medicaid beneficiaries.
As we heard in last week's hearing, Medicaid is a critically
important program that provides health care services for the poorest
and sickest Americans. However, Medicaid also faces a number of
challenges--including the perverse incentives it provides for states to
improperly obtain additional federal funding and how restrictive
federal statutory mandates limit states' ability to best address
beneficiary needs with flexible benefit packages.
The need to better coordinate care is another challenge that
confronts the Medicaid program. While this challenge is not unique to
Medicaid, it is particularly relevant to the program, given the large
number of chronically ill patients who are Medicaid beneficiaries.
Traditional fee-for-service Medicaid programs have been singularly
ineffective in managing the health care needs of these patients. This
has contributed to rapidly increasing health care costs and
unsatisfactory clinical outcomes.
Clinical data shows just how poorly traditional Medicaid does at
treating many beneficiaries with chronic conditions. For example, data
from one large Florida hospital revealed that 90 percent of Medicaid
patients with diabetic symptoms were admitted through the emergency
room. This is deeply disturbing--diabetes is an eminently manageable
disease, which can be controlled through a regimen of physician
monitoring, diet, exercise and regular testing of blood insulin. It is
unacceptable that, in some cases, 90 percent of diabetic Medicaid
patients are seeking hospital admissions through the emergency room,
rather than obtaining their treatments under the direction and care of
a primary care physician.
Unfortunately, this situation is not limited to the treatment of
diabetes. The same hospital I referenced earlier also reported
similarly high emergency room admission rates for Medicaid patients
with hypertension and congestive heart failure. Medicaid's failure to
adequately coordinate the care of these patients leads to increased
utilization of expensive inpatient hospital services, increased costs
for the program, and worse clinical outcomes for patients.
These types of failures have prompted several states to
affirmatively act to better coordinate Medicaid beneficiaries' care.
These efforts have included contracting with disease management
organizations, managed care plans and a variety of other innovative
state-sponsored initiatives to promote improved clinical outcomes. All
of these programs share several characteristics--including an emphasis
on better coordination of medical services and pharmaceutical benefits,
increased patient education, and efforts to ensure greater adherence to
clinical treatment guidelines.
States using these programs have experienced some dramatic
successes, including significant reductions in the number of necessary
hospitalizations and emergency room visits. In addition, managed care
initiatives have produced significant program savings by reducing the
amounts spent on pharmaceuticals, durable medical equipment and certain
acute care services.
We can learn from some of these successes, as we consider ideas to
reform Medicaid. While the coordination of care for Medicaid
beneficiaries creates significant opportunities to improve patients'
quality of care, it also raises significant concerns. To date, efforts
to implement effective coordination of care initiatives have been
hampered by a lack of adequate performance measures and analysis of
clinical outcomes that can demonstrate whether these programs deliver
the benefits they promised. Several recent reports have criticized the
overall cost-effectiveness of certain coordination of care programs.
Moreover, some efforts that have been described as coordination of care
reforms, instead have simply replicated existing flawed Medicaid
structures.
I believe we owe it to Medicaid's beneficiaries to provide them
with better care. Improved coordination of care holds the potential to
produce significant Medicaid savings, but more importantly, to also
dramatically increase the quality of care that beneficiaries receive. I
look forward to hearing the testimony of the witnesses, who will
hopefully help us identify how we can achieve these important goals.
Mr. Bilirakis. We will go right into the panel. Your
written statements are part of the record and I hope what you
would do would be to supplement those statements. We will set
the clock for 5 minutes for each of you.
Obviously, if you are on a roll and 5 minutes is up, I am
certainly not going to cut you off, but we would appreciate if
you could stay as close to it as you can, because we will be
asking questions, and you will have an opportunity to
supplement some of your statements that way.
The panel consists of Ms. Chris Selecky, the chief
executive officer of LifeMasters Support SelfCare, Inc. She is
testifying on behalf of the Disease Management Association of
America; Mr. Dan Hilferty, president and CEO of the Keystone
Mercy Health Plan of Philadelphia, testifying on behalf of the
American Association of Health Plans; Dr. Rhonda Medows,
Secretary of the Florida Agency for Health Care Administration,
Tallahassee, Florida, testifying on behalf of the State of
Florida; Mr. Jeffrey Simms, assistant director of North
Carolina Division of Medical Assistance, testifying on behalf
of North Carolina, so to speak; and Ms. Melanie Bella,
Assistant Secretary, Office of Medicaid Policy and Planning, on
behalf of Indiana.
Welcome, again.
Thank you so very much for taking time to be up here, and
we will start off with Ms. Selecky.
Please proceed.
STATEMENTS OF CHRISTOBEL E. SELECKY, CHIEF EXECUTIVE OFFICER,
LIFEMASTERS SUPPORT SELFCARE, INC., ON BEHALF OF THE DISEASE
MANAGEMENT ASSOCIATION OF AMERICA; DANIEL J. HILFERTY,
PRESIDENT AND CEO, KEYSTONE MERCY HEALTH PLAN OF PHILADELPHIA,
ON BEHALF OF THE AMERICAN ASSOCIATION OF HEALTH PLANS; RHONDA
MEDOWS, SECRETARY, FLORIDA AGENCY FOR HEALTH CARE
ADMINISTRATION, ON BEHALF OF STATE OF FLORIDA; JEFFREY SIMMS,
ASSISTANT DIRECTOR, NORTH CAROLINA DIVISION OF MEDICAL
ASSISTANCE; AND MELANIE M. BELLA, ASSISTANT SECRETARY, OFFICE
OF MEDICAID POLICY AND PLANNING, STATE OF INDIANA
Ms. Selecky. Good morning.
Thank you, Mr. Chairman and Representative Wilson, for
inviting me to speak before the committee today.
My name is Christobel Selecky, and I am the-president elect
of the Disease Management Association of America, which is a
non-profit interdisciplinary association dedicated to the
advancement of health improvement for people with chronic
conditions.
I am also the CEO of LifeMasters Supported SelfCare, a
privately held disease management organization that provides
coaching, education, and support to more than 300,000 people
nationwide.
We are fully accredited by the National Committee for
Quality Assurance to provide disease management services to
people with asthma, congestive heart failure, coronary artery
disease, COPD, and diabetes, and manage the other conditions
that go along with these diseases like depression and high
blood pressure.
Our company was founded by a physician, almost 10 years
ago, for the sole purpose of providing disease management
services. We have provided these services to thousands of
Medicaid beneficiaries for several years and currently work
with several thousands of beneficiaries in Florida and New
Mexico.
We were one of the first disease management organizations
to be selected by Florida to provide services to their fee-for-
service beneficiaries and we are pleased to be continuing with
that relationship.
In the first 2 years of that program, we were able to
provide the State almost $4.5 million in real bottom line cost
savings on an average population of just 2,500 beneficiaries
with congestive heart failures. This represented a 5.6 percent
net reduction in health care costs. These savings were the
result of significant reductions in health care service
utilization; for example, emergency hospitalizations went down
by almost 40 percent.
In addition, beneficiaries received increased levels of
evidence based care from their physicians, such as the 78
percent increase in annual cholesterol screenings. These
programs work equally well in fee-for-service and managed care
plans. In New Mexico, nurses in our Albuquerque call center
provide our program to Medicaid beneficiaries with diabetes and
coronary artery disease who are members of the Presbyterian
health plan.
Disease management is one of those very rare win-win
opportunities in health care, in which the beneficiaries win
because they get a better quality of life. The physicians win
because they have the opportunity to manage their patients more
efficiently and the patients win because utilization and health
care costs are reduced. The beneficiaries we serve often have
multiple conditions, are taking several prescription drugs, see
many different physicians, and often experience complications
leading to expensive emergency hospitalizations. These
complications are caused by things like drug interactions, the
impact of lifestyle choices or the failure to correctly follow
the treatment plan prescribed by the physician.
Medicaid beneficiaries face additional challenges, such as
low levels of literacy, language barriers, frequent changes in
eligibility, problems with gaining access to primary care,
transients and other life issues making health care a secondary
concern and higher levels of mental-health issues than the
general population. Disease management programs identify and
work proactively with people to educate and support them in
making necessary lifestyle and behavior changes, to monitor
their condition in between office visits and to alert their
physicians to any changes in their patient's condition.
In Medicaid population, disease management organizations
have learned to make special efforts, such as finding
beneficiaries a medical home, coordinating transportation,
providing home assessments and training, adapting programs to
assess language, literacy and cultural issues and coordinating
with local mental health and social-service resources.
It has been our experience in several States that Medicaid
beneficiaries are hungry for the support and enhanced access to
care that disease management programs provide, and that they
participate in these programs at equal or higher levels than
our commercial populations.
It is critical that our country begin to address the needs
of our chronically ill Medicaid beneficiaries, now. In spite of
best efforts, the Medicaid fee-for-service program is not set
up to facilitate the program of optimal care for beneficiaries.
We believe the solution is to integrate fully integrated fully
accredited disease management programs into fee-for-service and
manage Medicaid according to the following principles. There
should be no discrimination against beneficiaries who currently
lack access to the benefits of disease management. These
programs should be made available to all Medicaid and duly
eligible beneficiaries, regardless of whether they were in
managed care or fee-for-service.
Medicaid fee-for-service programs should consider directly
contracting with accountable disease management organizations
which can ramp up quickly to immediately begin delivering the
benefits of these services on a population wide basis with
financial arrangement that would result at a minimum budget
neutrality.
Results of disease management efforts should be measured
and reported objectively, using consistent standardized
methods, and disease management providers should be selected
based on demonstrated and documented ability to deliver
positive financial and quality outcomes.
Based on the results from several States, we believe that a
comprehensive disease management strategy could deliver cost
savings to the Medicaid population into the billion dollars
annually while concurrently improving access to care, quality
of life, and health outcomes.
I appreciate the opportunity to share my views of
experience in disease management with you and look forward to
trying to answer some of your questions.
[The prepared statement of Christobel E. Selecky follows:]
Prepared Statement of Christobel E. Selecky, President-elect, Disease
Management Association of America, Chief Executive Officer, LifeMasters
Supported SelfCare, Inc.
The Disease Management Association of America (DMAA) is a non-
profit, voluntary membership organization, founded in March of 1999,
which represents all aspects of the disease management community.
Creation of the association was in response to the continued growth
of disease management in the United States. The increasing number of
stakeholders dependent on the ``promise'' of disease management for
cost effective, quality healthcare in this new millennium has created a
need for a single voice and a more scientific approach to the
measurement of the success of disease management programs.
DMAA has established an industry-standard definition of qualified
DM programs and entities. The DMAA definition, established in
consultation with primary care and specialty physicians and
representing private practice, health plan, and institutional
perspectives, is as follows:
Disease management is a system of coordinated healthcare
interventions and communications for populations with
conditions in which patient self-care efforts are significant,
supporting the physician/patient relationship and their plan of
care;
Emphasizes prevention of exacerbations and complications utilizing
evidence-based practice guidelines and patient empowerment
strategies; and
Evaluates clinical, humanistic and economic outcomes on an ongoing
basis with the goal of improving overall health.
Disease management services provided to an individual must include:
Population identification processes;
Evidence-based practice guidelines
Collaborative practice models to include physician and support-
service providers;
Patient self-management education (e.g. primary prevention,
behavior modification programs, and compliance/
surveillance);
Process and outcomes measurement, evaluation and management, and
routine reporting; and
Feedback loop (e.g. communication with patient, physician, health
plan, and ancillary providers and practice profiling)
The Disease Management Organization which I am privileged to lead,
LifeMasters ' Supported SelfCareSM, Inc., has extensive
experience in and NCQA accreditation for providing disease management
programs to patients with CHF, COPD, CAD, Diabetes, and Asthma and has
demonstrated that a multi-disciplinary Disease Management program
including patient education, interactive vital sign and symptom
monitoring, nurse support and physician intervention can significantly
reduce unnecessary utilization and improve quality of care. The company
was founded by a physician in 1994 and currently provides services to
more than 300,000 individuals nationwide through its contracts with
healthplans, employers, and government agencies. The LifeMasters
' service model has served as the basis for five major
published outcomes papers.
States are experiencing unprecedented budget deficits as a result
of the economic recession and its resultant impact on tax revenues.
Following more than a decade of economic expansion, state tax revenues
are falling for the third year in a row and most states have already
dipped into their ``rainy day'' funds to make ends meet in the previous
2 years. This year's budget balancing promises to be the most difficult
in recent times.
State Medicaid agencies are having an exceptionally difficult time
making ends meet as the result of rising health care costs and
increasing enrollments over the past several years.
Most states are contemplating Medicaid program reductions in the
form of: 1. Reduced benefits; 2. Tightened eligibility requirements; 3.
Lower health care provider rates; and 4. Moving Medicaid fee-for-
service beneficiaries to managed care.
For most poor people, low-income children, the frail elderly, and
the blind and disabled, Medicaid is often the only source of health
care coverage available to them. Reducing eligibility and access to
care for these groups may offer short-term savings by shifting costs
from the state to the safety net providers and the community. But the
economic hardship placed on safety net providers today, however, will
likely have to be swallowed by the state in subsequent years. To stop
this cycle, we must explore alternative strategies that do more than
shift costs.
To identify successful cost-cutting strategies for Medicaid it
makes sense to begin with an understanding of what drives health care
costs in this population. A report by the Centers for Disease Control
and Prevention's Chronic Disease Center estimates that 70% of the
nation's medical costs are attributable to the treatment of people with
chronic disease(s). In addition, 75% of the nation's deaths result from
complications associated with chronic disease. In a recent report in
California, where LifeMasters is headquartered, the Legislative
Analyst's Office (LAO) estimated that more than 25% of adult
beneficiaries, or over 700,000 people, enrolled in Medi-Cal have at
least one chronic condition. The greatest concentration of chronic
disease is among the aged, blind and disabled (ABD) population where
the California LAO estimated that 440,000 ABD beneficiaries cost the
state $5.3 billion in 2001, an average annual cost of $12,000 per
beneficiary. On a national basis, the elderly and disabled constitute
25% of Medicaid beneficiaries but account for two thirds of the
healthcare costs.
Nationally, the direct cost of treating people with chronic
disease(s) is estimated to be at least $510 billion this year and will
soar to $1.07 trillion by the year 2020. Three diseases, diabetes,
congestive heart failure (CHF) and coronary artery disease (CAD),
account for $250 billion or more in annual direct costs, and $429.2
billion in total costs (including lost productivity, wages, etc.). Many
of these expenditures are related to preventable repeated
hospitalizations and emergency room visits. During the next 30 years,
as the U.S. population ages, the number of individuals and estimated
cost of care for people with chronic disease is expected to grow
dramatically. The time for the states and the federal government to
devise proactive cost reduction and quality improvement strategies is
now.
Further compounding problems for states are the health care
challenges caused by disparities of race, class, culture and ethnicity
facing the nation's elderly and disabled poor. Barriers of education
and language directly impact a patient's ability to access care. These
patients may not seek care, or may rely solely on emergency room
visits, and may be non-compliant with follow-up. These factors
contribute to the high cost of care, and relatively poor outcomes, for
Medicaid eligible patients. The chart displays the disproportionate
burden of diabetes facing non-whites.
Cardiovascular disease is a leading cause of morbidity and
mortality for all racial and ethnic groups, but as with diabetes, non-
whites disproportionately experience all risk factors (excepting
tobacco use) and rates of complications. Hispanics are also more likely
to have high blood pressure and elevated cholesterol, major risk
factors for cardiovascular disease. In addition, African Americans and
other minorities experience death rates from diabetes and heart disease
that are 50-100% higher than their Caucasian counterparts.
As Congress and the states ponder solutions to this problem, we
urge you to consider implementing an innovative approach to managing
health called disease management (DM). DM has taken shape over the past
several years and is showing great promise to deliver better care at
lower cost. These results have been achieved while simultaneously
increasing beneficiary access to care, enhancing patient satisfaction
with their healthcare providers, and improving clinical outcomes.
Although there is no singular solution to cure the complex problems
facing Medicaid today, DM is one option that can immediately begin to
reduce costs while improving health outcomes. Based on experience
managing similar populations, it is estimated that DM could save the
states many millions of dollars.
Nearly 25 states have initiated disease management efforts, at
least at a pilot project level, and eight have initiated comprehensive
programs similar to the ones described below. Furthermore, the U. S.
Department of Health and Human Services (HHS) and Centers for Medicare
and Medicaid Services (CMS) have gained Congressional approval to begin
larger scale demonstration projects with Medicare and Medicare/Medicaid
dual eligible populations with chronic disease. Several large awards
were made late in 2002 and several other DM demonstrations are expected
to be awarded and implemented in 2003 and 2004.
DESCRIPTION OF THE PROBLEM
When Medicaid was created in 1965 (Title XIX), the intent was to
improve the medical care being delivered under the public assistance
programs. Beneficiaries were expected to enter the program for a period
of time while they needed public assistance and then move back into the
private sector. Consequently, most Medicaid programs were originally
rooted in the provision of acute care under a medical treatment model
that largely ignored prevention, self-management, peer support, and
management of complex, co-morbid conditions.
Most people receiving public assistance, however, stay on service
longer than expected. Coupled with advances in the pharmaceutical and
clinical management of chronic conditions, people now have
substantially longer life expectancies, extending the period of
eligibility for a larger percentage of the population than was
envisioned in 1965. This added longevity has contributed greatly to the
steadily growing number of beneficiaries dually eligible for Medicaid
and Medicare. The U.S. Census Bureau indicates that life expectancy
rates have increased steadily since 1965, as follows:
------------------------------------------------------------------------
Life expectancy at birth, both
Year sexes, all races (years)
------------------------------------------------------------------------
1965............................... 70.2
1970............................... 70.8
1975............................... 72.6
1980............................... 73.7
1985............................... 74.7
1990............................... 75.4
1995............................... 75.8
2000 Projections................... 76.4
2010 Projections................... 77.4
------------------------------------------------------------------------
As a result, chronic diseases, such as arthritis, asthma, cancer,
chronic obstructive pulmonary disease, CHF, depression, and diabetes
account for 60 percent of medical costs in the United States.
Cardiovascular disease (principally high blood pressure, heart disease,
and stroke) is the leading cause of death among both men and women and
across all racial and ethnic groups. About 58 million Americans live
with some form of the disease. In 1999 alone, cardiovascular disease
cost the nation an estimated $287 billion in health care expenditures
and lost productivity, and this burden is growing as the population
ages.
Medicare has recognized that an acute care system is no longer
appropriate where the major killers and cost drivers of our era are
chronic conditions. Moreover, it has reacted by exploring high-tech,
innovative delivery systems, such as DM. Medicare has thus far lacked
the legislative authority, however, to implement its demonstrations on
a beneficiary-wide scale to provide fair access to all fee for service
beneficiaries. On the state level, in the past two years, legislation
has been passed in several states to fund DM. As many as two dozen
states considered DM legislation in their recent legislative sessions.
Those states undertaking DM have elected not to cover dually
eligible beneficiaries in their DM projects since the state would be
primarily responsible for paying the cost of the DM program, most
savings achieved through DM, however, would accrue to CMS (this is the
result of Medicare being the primary payor and states are generally
being at risk for only pharmacy, Medicare co-payments and
transportation costs for this population). In fact, many beneficiaries
enrolled in DM programs in FFS Medicaid lose this benefit when they
become eligible for Medicare. Former CMS Deputy Administrator Ruben
King-Shaw made it clear that CMS is willing to approve waivers that
would allow states to share in any savings achieved through DM efforts
with dually eligible beneficiaries. CMS is also reviewing
``unsolicited'' demonstration projects for the management of dual
eligibles with chronic disease, whereby CMS would fund the DM project.
Like the ABD population, dual eligibles have chronic disease
prevalence rates much higher than the overall Medicaid population. For
example, CHF prevalence in the dual eligible population may approach
10% while the prevalence in the general population is less than 1%. The
average monthly cost for dual eligibles with CHF is approximately
$1,500 to $2,000 compared to a $200 to $300 monthly cost for the
overall Medicaid population. Whether or not the states elect to offer
DM services for this population will likely depend on the ability of
the states to negotiate shared cost savings with CMS or on having CMS
fund DM services as part of a CMS demonstration project.
Historically, a small proportion of Medicaid beneficiaries have
accounted for a major proportion of Medicaid expenditures. In the fee-
for-service environment, health care for individuals with chronic
illness has often been fragmented and poorly coordinated across
multiple health care providers and multiple sites of care. Evidence-
based practice guidelines have not always been followed, nor have
patients always been taught how best to care for themselves. These
shortcomings are particularly true for patients served under
reimbursement systems in which providers lack incentives for
controlling the frequency, mix, and intensity of services, and in which
providers have limited accountability for the outcomes of care, such as
fee for service Medicaid.
In its current form, the health care system in not equipped to
educate, monitor or support these very sick patients on a longitudinal
basis to ensure proper coordination of care and compliance with complex
treatment regimens. For fee for service Medicaid beneficiaries, this
problem is exacerbated by the lack of any medical management or quality
improvement infrastructure. The infrastructure offered by DM programs
fills these gaps resulting in better human and financial outcomes.
Disease managers provide a safety net for seriously and chronically
ill patients in between their physician visits, and are frequently
credited with helping patients with chronic disease avoid unnecessary
hospitalizations, unnecessary emergency room (ER) visits, surgery, and
other more invasive care. Instead of relying solely on the physician-
based care system (which, under managed care, and even in fee for
service, has suffered serious and often irrational restraints from
formularies, utilization review, and incentives to reduce doctor-
patient consultation time), DM programs typically provide access to
health care professionals on a 24-hour per day/ 7-day per week basis.
Although disease managers are typically nurses, dietitians, health
educators, social workers, and others who do not take the place of the
primary care physician, they bridge the care management gap that often
exists for patients between physician office visits. Given the
propensity by many Medicaid beneficiaries to use the ER for primary
care, DM can act as a means of educating patients on the proper use of
the health care system, thus directing patients to primary care, as
well as coordinating a patient's care across a variety of care
settings, i.e., ER, specialist, PCP, etc.
Disease managers also improve physicians' effectiveness by
providing real-time patient data and timely information on disease-
specific best practices protocols. Without a DM program, it is unlikely
that physicians can monitor patients effectively between (and even
during) visits, due to constraints on their time and office staff.
Given the few Medicaid Managed Care plans available to Medicaid
beneficiaries in rural settings, DM could serve to fill the access to
care and quality gap now being experienced in these areas and greatly
reduce overall costs. Since most DM services can be fully implemented
telephonically or via the Internet, rural patients in DM programs enjoy
significantly improved access to care. In addition, to the extent that
the DM programs succeed as expected, rural patients should not need as
many visits to hospitals or specialty facilities, which may be distant
from their homes and therefore avoided. Finally, on-line and telephonic
DM programs frequently offer patient self-management and informational
tools without cost, which improves access to services by the uninsured
and poor.
DM programs address issues raised by the Institute of Medicine
(IOM) regarding medical errors and quality of care. The IOM reports on
medical errors and the deteriorating quality of healthcare in America
1 argue that DM is not only integral to preventing medical
errors, but also to protecting and improving overall health care
quality, especially for the chronically ill. In the reports, the IOM
Committee on Quality of Health Care in America cites extensive evidence
that ``the nation's health care industry has foundered in its ability
to provide safe, high-quality care consistently to all Americans.
Reorganization and reform are urgently needed to fix what is now a
disjointed and inefficient system.''
---------------------------------------------------------------------------
\1\ Crossing the Quality Chasm: A New Health System for the 21st
Century, Committee on Quality of Health Care in America, Institute of
Medicine, National Academy Press, Washington, D.C. (2001).
---------------------------------------------------------------------------
The IOM quality of care report properly stresses the issues posed
by chronic conditions, and concludes that:
``clinicians, health care organizations, and purchasers--
companies or groups that compensate health care providers for
delivering services to patients--should focus on improving care
for common, chronic conditions such as heart disease, diabetes,
and asthma that are now the leading causes of illness in the
United States and consume a substantial portion of health care
resources. These ailments typically require care involving a
variety of clinicians and health care settings, over extended
periods of time.''
To address these issues, the IOM suggests that private and public
purchasers, health care organizations, clinicians, and patients should
work together to redesign health care processes in accordance with the
following rules:
Care based on continuous healing relationships. Patients should
receive care whenever they need it and in many forms, not just
face-to-face visits.
Customization based on patient needs and values. The system of care
should be designed to meet the most common types of needs, but
have the capability to respond to individual patient choices
and preferences.
The patient as the source of control. Patients should be given the
necessary information and the opportunity to exercise the
degree of control they choose over health care decisions that
affect them.
Shared knowledge and the free flow of information. Patients should
have unfettered access to their own medical information and to
clinical knowledge.
Evidence-based decision-making. Patients should receive care based on
the best available scientific knowledge.
Safety as a system property. Patients should be safe from injury
caused by the care system. Reducing risk and ensuring safety
require greater attention to systems that help prevent and
mitigate errors.
The need for transparency. The health care system should make
information available to patients and their families that
allows them to make informed decisions when selecting a health
plan, hospital, or clinical practice, or when choosing among
alternative treatments.
Anticipation of needs. The health care system should anticipate
patient needs, rather than simply reacting to events.
Continuous decrease in waste. The health care system should not waste
resources or patient time.
Cooperation among clinicians. Clinicians and institutions should
actively collaborate and communicate to ensure an appropriate
exchange of information and coordination of care.''
With regard to medical errors, the IOM emphasized that one of the
chief culprits in medical errors is the lack of care management and
coordination, resulting from the decentralized and fragmented nature of
the health care delivery system, and the multitude of unaffiliated
providers practicing in different settings without access to complete
medical record information or coordination.
The IOM reports are, in all respects, a call to action for, and a
validation of, the critical need to support and promote DM as a
solution to many of the problems besetting the health care system, both
public and private, managed care and fee-for-service. High-quality DM
programs focus directly on the chronic conditions that the IOM reports
consider most costly and ripe for new models of intervention, and
improve clinical and financial outcomes in every one of the areas
considered most problematic by the IOM.
ENHANCING CARE COORDINATION--DISEASE MANAGEMENT
The central premise behind DM is elegant in its simplicity. Simply
stated, the value proposition for DM is that ``healthier people cost
less.'' Put another way, if we can improve the health of the
population, we will reduce their demands on the health care system and
that reduced demand translates into lower costs. Chronic illness is a
major driver of health care costs. One reason for this is that many
chronically ill individuals experience acute episodes that require
expensive (and often traumatic) treatment in institutional settings.
The incidence of such episodes can be reduced or entirely avoided
through proper management of chronic conditions, as can the progressive
worsening of chronic conditions that leads to complications and co-
morbidities. Thus, if health care payors can efficiently deliver
interventions that result in improved management of their chronic
condition to those beneficiaries, quality improvement and cost savings
will result.
Candidates for DM services are typically identified through review
of their health insurance and available medical data by health insurers
and disease management organizations (DMOs), or by their primary care
providers. Disease managers then reach out to these individuals and, in
concert with their physicians, enroll them in DM programs.
Many of the interventions that can be provided to individuals with
these chronic illnesses are often relatively simple. For example, great
progress can be made by promoting smoking cessation, improvements in
diet and exercise, and teaching patients to better self-manage many
aspects of their condition like blood glucose level self-monitoring and
adherence with prescription drug regimens. These interventions are
supported by regularized, ongoing communication between beneficiaries,
care providers and disease managers through a variety of media
including phone, mail and electronic, and, when warranted, in-home
visits, that serves to promote adherence, monitor clinical status,
ensure a continuum of care, and to proactively identify and address
situations that could lead to avoidable acute events. Most DMOs have
proven adept at addressing populations with multiple conditions, which
is significant because a high percentage of individuals with chronic
disease have more than one condition (co-morbidity).
One challenge in delivering effective DM services lies with the
fact that the beneficiary population can be a difficult one to impact.
Often, the harmful behaviors and habits that DM programs seek to
address have become highly ingrained over decades. In other cases,
beneficiaries are depressed as a consequence of their condition, have
grown skeptical of health care interventions, and may have developed
hostility toward the health care system. DM programs have developed
techniques for successfully reaching these populations and are able to
uncover and motivate the underlying desire of most chronically ill
individuals for improved quality of life.
Another important feature of disease management is the integration
with the beneficiary's personal physician. Many DM programs assist the
physician as well as the patient by helping to provide evidence-based
practice guidelines specific to their patients and their conditions. DM
programs develop programs and techniques for reaching out to physicians
and have generally been successful in achieving positive physician
satisfaction and participation.
DM works. Peer reviewed studies show that DM can have a significant
impact on both the cost and quality of care and health outcomes.
OUTCOMES
The state of Florida was one of the first states to offer disease
management services to beneficiaries eligible for Medicaid fee for
service and Primary Care Case Management (PCCM). In LifeMasters
' program for Florida Medicaid beneficiaries with Congestive
Heart Failure, we were able to reduce healthcare expenditures over a
two-year period by 16.3%, resulting in a net savings to the state
(after paying for program costs) of $4.4 million for an average of just
2,500 beneficiaries. Other states have launched their own DM
initiatives including Washington, Colorado, Texas, Oregon, Mississippi,
Ohio, Kansas, Idaho, Missouri and Arkansas to name just a few. There
are several DM Organizations that have extensive experience meeting the
distinct needs of Medicaid populations.
Florida Medicaid Results (Population-based CHF Program)
----------------------------------------------------------------------------------------------------------------
Intervention Period
Indicator Baseline Year (Two Years) Percent Change/Comment
----------------------------------------------------------------------------------------------------------------
Total Medical Claims/Year............ $77,727,365 (Projected $65,065,548 (Two year -16.3%
two year costs). actual costs).
Hospital days/Year................... 8,859 per 1000 members. 5,431 per 1000 members. -38.7%
Percent of beneficiaries on ACE 58.1%.................. 76.5%.................. 32%
inhibitor/angiotensin receptor
blocker therapy.
Percent of beneficiaries on beta 30.2%.................. 44.1%.................. 46%
blockers.
Percent of beneficiaries receiving an 30.3%.................. 53.8%.................. 78%
annual cholesterol screening.
Percent of patients reporting N/A.................... 69%.................... N/A
abstaining from smoking.
Percent of patients compliant with N/A.................... 98%.................... N/A
drug treatment plan.
Percent of patients compliant with N/A.................... 77-85%................. Depends on risk
dietary restrictions. category and month
measured
Compliant with drug treatment plan... N/A.................... 98%.................... N/A
----------------------------------------------------------------------------------------------------------------
LifeMasters also provides services to managed care Medicaid
beneficiaries through a relationship with Presbyterian Health Plan in
New Mexico. Presbyterian has 133,000 Medicaid beneficiaries. Of this
number, there are 2,100 beneficiaries with Coronary Artery Disease
(CAD) and Diabetes enrolled in the disease management program. While it
is too early in the program to have clinical, cost, and quality data
available, we have found the same level of receptivity to the program
as we experienced with fee for service Medicaid beneficiaries in
Florida. One of our disease management nurses said of one of her
program participants: ``When I first started calling [the participant]
in May, she was stressed and depressed and frustrated with her foot
pain. Since that time, she has started walking a few miles 4 times a
week and lifting weights. She has lost 10+ lbs and her energy and
spirits are higher than ever. After a trip to her podiatrist, her feet
are feeling better. She often thanks me for calling her and holding her
accountable to keep on top of her DM and exercising. Without the
program she doesn't think she would be doing so well.''
LifeMasters has also provided services to managed care Medicaid
beneficiaries through a relationship with Fallon Community Health Plan,
which has been ranked the number one HMO in America four times over the
past several years: twice by Newsweek (1999, 1996) and twice by U.S.
News and World Report (1998, 1996). Beginning in 1999, Fallon's members
with diabetes were enrolled in the LifeMasters diabetes management
program. According to Val Slayton, MD, Fallon's former Chief Medical
Officer, the cost savings achieved with the Medicare (9.2%) and
Medicaid (42.9% for a relatively small population) populations have
been larger than those in the Commercial group (4.7%) for patients with
diabetes in the first year on a per member, per month (pmpm) basis
compared with baseline figures (see below). Diabetic claims cost on a
PMPM basis fell from $691 to $632.
Fallon Community Health Plan Results (Diabetes) Program Results after 1 Year
----------------------------------------------------------------------------------------------------------------
Percent Change/
Indicator Baseline Year Intervention Period Comment
----------------------------------------------------------------------------------------------------------------
Total Medical Claims/Year.............. $717.80................... $486.93.................. -42.9%
Hospital days/Year..................... 1,536 per 1000............ 1,173 per 1000........... -23.6%
Cardiac (CHF+CAD) Days/Year............ 284 per 1000.............. 69 per 1000.............. -75.6%
Average HbA1c Value (entire population) 8.2%...................... 7.5%..................... -8.5%
----------------------------------------------------------------------------------------------------------------
Other Disease Management Organizations have had success in
deploying DM interventions in Medicaid populations.
McKesson Corporation has extensive expertise providing disease and
demand management experience through direct contracting with State
Medicaid programs including contracts with the Washington State Medical
Assistance Administration (MAA), the Oregon Medical Assistance Program,
Florida's Agency for Health Care Administration (AHCA), the Mississippi
Division of Medicaid, and Colorado's Division of Health Care Policy and
Administration. Furthermore, the states of New Hampshire and Montana
have selected McKesson to provide disease management for their Medicaid
fee-for-service population.
Initial results for Washington MAA (asthma, diabetes and heart
failure) have demonstrated significant clinical and economic
improvement. The state of Washington recently released their first year
estimated net savings from their disease management programs. The
results from the state show greater than $1.5 million of first year
savings for the 18,000 Medicaid recipients eligible for the service.
Savings of $900,000 were noted in the diabetes population, $375,000 for
heart failure, and $250,000 for asthma.
Columbia United Providers, a Medicaid managed care provider based
in Vancouver, Washington has had significant success in implementing
behavior changes among members enrolled in an asthma DM program. At the
time the plan's members first enrolled in the asthma program
approximately 8% had an action plan; at six months, nearly 46% had such
a plan--an increase of 450%. Members taking asthma medication every day
to control symptoms increased to 33% at six months from 29% at
enrollment. The analysis of medical and pharmacy claims (using a
matched cohort design) for this Medicaid Program was quite positive and
resulted in a very positive financial return to the client ($2.25 ROI).
A second managed Medicaid program in the Northeast completed an
asthma program for its identified members, showing highly significant
reductions in inpatient, emergency room and outpatient symptomatic
office visits utilization when compared to a matched cohort of non-
participating asthmatics (p< .01 for all comparisons), resulting in a
very favorable financial return ($1.61 ROI).
In addition to these Medicaid-specific analyses, McKesson has
completed 9 medical claims analyses for commercial asthma programs; 13
completed studies for commercial diabetes programs; and 10 completed
studies for commercial heart failure programs. The results of these
studies demonstrate improvements in health status and net reductions in
claims costs resulting in favorable ROI.
The experience of McKesson' Care Support Programs demonstrates
their efficacy and relevance to Medicaid populations. These studies
strongly suggest that structured DM programs can create positive
clinical and financial outcomes while promoting enhanced self-
management through continued support, education, and patient
involvement.
LifeMasters and McKesson are not unique in achieving results such
as those described above. As the industry matures, other companies are
also demonstrating the economic and qualitative value of DM services in
the commercial, Medicare+Choice, and Medicaid arenas
DM PROGRAMS ARE BUDGET NEUTRAL IN THE FIRST YEAR OF IMPLEMENTATION
Most DM programs expect to generate net savings during the first
contract year (defined as savings greater than the cost of the DM
program), with the greatest program impact being realized in the second
half of the year, once the majority of program prospects are enrolled.
Further savings are expected in years two and beyond as the program
staff has more time to interact with program participants and their
physicians. Savings are generally calculated by comparing per member
per month healthcare costs for the year(s) in which the program was in
effect with a per member per month baseline which is adjusted for
medical inflation. In some cases, a control group methodology is
employed which compares the cost of people who had access to the
program with a group of similar people who did not. This is
particularly useful because chronic disease is progressive in nature
and costs can be expected to increase in the absence of a program.
However, there are ethical concerns about denying a program to people
who could benefit from it. The table below illustrates this ability of
a CHF disease management program to reduce cost trend as well as actual
cost.
Which disease(s) the states elect to focus their immediate
attention on will depend largely on the prevalence and cost of
disease(s) in the Medicaid population and the states' specific goals.
For example, if the state's immediate goal is to maximize return on
investment and savings in the first year, the likely choice is to
manage beneficiaries with diabetes, CHF and CAD. People with these
conditions are costly, the diseases are closely related (many people
with diabetes are co-morbid with CHF or CAD) and a significant
reduction in hospitalizations and ER visits can happen very quickly. If
the state decides to move in that direction, it is recommended that the
state contract with one organization to manage these conditions in a
specific geography. This approach leads to much better coordination of
care and less confusion among patients and their physicians.
RECOMMENDATIONS
DMAA believes that comprehensive disease management, if fully
employed in Medicaid, can:
Achieve the objective of better addressing preventive care and
chronic illness under Medicaid
Improve the safety and quality of care by adhering to evidence-based
treatment guidelines and outcomes data, and by providing
patients with a safety net between physician and hospital
visits, thereby reducing drug and treatment errors and
improving care coordination
Improve access to care by around the clock nursing and high-tech
contacts, and by assisting rural caregivers and their patients
who do not have the benefit of easy entree to in-person care
Improve patient self-management of, and responsibility for,
preventing and treating their conditions by its innovations in
patient-centered and collaborative education
Improve financial cost containment without sacrificing quality or
patient satisfaction by serving as an alternative to the
increasingly unacceptable cost-containment techniques of
managed care, such as utilization review, gatekeeper
restrictions, referral limitations, and drug restrictions
Enhance efforts in the public health arena by providing health
improvement programs on a population basis; creating financial
incentives to promote and deliver preventive interventions on a
large scale using advanced outreach technologies, especially
secondary preventive measures; and encouraging those segments
of the private sector that have not yet embraced DM to do so.
DMAA supports the integration of fully accredited DM programs into
fee for service and managed Medicaid according to the following
principles endorsed by DMAA:
There should be no discrimination against beneficiaries who currently
lack access to the benefits of DM programs available to some
managed care and fee for service Medicaid enrollees
Medicaid fee for service programs should directly contract with DM
organizations to offer such benefits on a population basis.
Congress and the states should focus their initial DM efforts on
managing beneficiaries with the highest cost, highest prevalence
conditions where evidence exists that changes in lifestyle, monitoring
and early intervention reduce costs and improve health outcomes.
With these criteria in mind, the first priority should be to
disease manage aged, blind and disabled beneficiaries with diabetes,
congestive heart failure (CHF), coronary artery disease (CAD), chronic
obstructive pulmonary disease (COPD) or asthma. A secondary emphasis
should focus on managing all fee for service beneficiaries and dual
eligibles with these same chronic illnesses. States should focus their
efforts on beneficiaries with these diseases for a number of reasons
including:
Diabetes, CHF, CAD, COPD and asthma affect more than 20% of the
entire Medicaid aged, blind, disabled and dual eligible
populations while accounting for as much as 75% or more of
total costs.
Incidence of these diseases continues to grow at a significant rate--
costs will continue to increase over time.
These debilitating diseases greatly diminish an individual's quality
of life and have a high rate of morbidity and premature
mortality.
Non-whites are disproportionately affected by these chronic diseases,
experiencing much higher morbidity and mortality rates than
their white counterparts. Focusing on managing people with
these diseases helps to minimize the impact of the racial and
ethnic disparities experienced in health care.
Diabetes, CHF and CAD are closely related, with a great percentage of
people with diabetes developing CHF and/or CAD as a result of
the cardiovascular damage caused by their diabetes. People with
diabetes are frequently co-morbid with these conditions.
Typically, investing in DM for these groups delivers a return on
investment of 150% to 250% in the first year.
Asthma prevalence rates among low-income children and adults make it
a high public health priority. First year ROI experienced
managing people with asthma is break even or slightly positive.
Much of the human and economic cost associated with these diseases
can be positively impacted through longitudinal health
management, lifestyle modification, disease-specific vital
signs and symptoms monitoring, and early intervention. These
efforts have been shown to reduce or delay health complications
while lowering overall costs.
CONCLUSION
Based on documented cost reductions and quality improvements from
Medicaid DM programs in selected states, it is likely that a
comprehensive DM strategy covering beneficiaries with diabetes, CHF,
CAD, COPD, asthma and ESRD could deliver cost savings to the Medicaid
program into the billions of dollars annually while concurrently
improving access to care, beneficiary quality of life and health
outcomes.
The most innovative states along with Medicare+Choice and private
sector organizations have benefited from high quality DM, and these
organizations now have irrefutable evidence that these programs have
not only improved the delivery of healthcare services, but have also
achieved impressive clinical quality improvements and cost savings.
Based on the demonstrated evidence of successful clinical and financial
outcomes of disease management programs, DMAA and LifeMasters believe
that our nation should move to offer disease management services to all
Medicaid beneficiaries with chronic disease.
Mr. Bilirakis. Thank you very much, Ms. Selecky.
Mr. Hilferty?
STATEMENT OF DANIEL J. HILFERTY
Mr. Hilferty. Mr. Chairman and members of the subcommittee,
my name is Daniel Hilferty. I am president and CEO of
AmeriHealth Mercy/Keystone Mercy Health Plan. AmeriHealth Mercy
and its family of health plans serve over 1.3 million Medicaid
beneficiaries in six States, Pennsylvania, New Jersey,
Kentucky, South Carolina, Virginia, and California.
As a mission-driven organization, AmeriHealth Mercy
specializes in managing the delivery of health care services
and providing health care management services for organizations
serving enrollees in Medicaid managed care programs and State
children's health insurance programs.
I appreciate this opportunity to testify about the value of
the private sector health plans bring to the Medicaid program.
AmeriHealth Mercy/Keystone Mercy has played a leading role in
improving health care quality for Medicaid beneficiaries.
I am also testifying today on behalf of the American
Association of Health Plans.
Today, I will focus on strategies Medicaid's managed care
plans are implementing to improve the health care system for
Medicaid enrollees. My testimony will also emphasize the
importance of ensuring that State Medicaid managed care
programs are funded at levels that support the participation of
Medicaid managed care plans and their providers.
At the same time, I will discuss the important role that
plans are playing in delivering cost-effective health coverage
and ensuring that State Medicaid programs receive maximum value
for their limited resources at a time when State budgets are
severely restrained.
First I would like to talk about coordination of care.
Health plans participating in State Medicaid-managed care
programs have developed systems of coordinating care for
ensuring that Medicaid beneficiaries receive all medically
appropriate health care services. Covered under the State
Medicaid managed-care program on a timely basis.
As a result, physicians services, hospital care,
prescription drugs, and other health care services are
integrated and delivered through an organized system whose
overriding purpose is to prevent illness, improve health
status, and employ the best practices to swiftly treat medical
conditions that occur. This approach is far superior to a
system of uncoordinated care, in which patients are forced to
navigate a fragmented health care system on their own.
AmeriHealth Mercy serves a high percentage of non-
traditional Medicaid recipients, the sickest of the sick, those
accounting for the highest cost, the aged, blind, and disabled.
AmeriHealth Mercy is at risk for the total health care of the
patient/member.
Therefore, we have designed a population-based approach to
care management, which has enhanced the quality of life for our
members and produced significant annual savings for these high
cost members. In terms of preventive health care services,
instead of focusing solely on treating beneficiaries when they
are sick or injured, Medicare-managed care plans place a strong
emphasis on preventive health care services to keep
beneficiaries healthy, detect diseases at an early stage, and
avoid preventable illnesses.
Passport health plan owned by University Health Care in
Kentucky and managed by our organization has improved
adolescent immunizations by over 160 percent, from 1997 to 2002
and increased well child visits in the first 15 months of life
by 216 percent.
Over 90 percent of our pregnant members receive prenatal
care, meeting the standards of the National Committee for
Quality Assurance for whom passport has earned the highest
level of accreditation, excellent in all categories; in fact,
each of our entities has achieved NCQA status of outstanding or
excellent.
In terms of disease management services, Medicaid
management care plans have also introduced the concept of
disease management programs to Medicaid. Improving quality of
care for beneficiaries with chronic conditions by focusing on
the comprehensive care of patients over time, rather than
individual episodes of care.
AmeriHealth Mercy's disease management programs have
improved health outcomes and significantly lowered the cost of
care for the highest cost patients. These programs have
improved patient care and achieved major savings for small but
very ill population groups; for example, our hemophilia case
management program has reduced hospitalizations by 40 percent
for 60 members, thus saving $2 million annually in the cost of
blood factor and overall medical care.
In terms of innovations by Medicaid health plans, Medicaid-
managed care plans have developed a wide range of innovative
programs to improve the health status of Medicaid
beneficiaries; for example, our plan in Pennsylvania, Keystone
Mercy, is promoting preventive health care for Medicaid through
a health ministry program for women.
This program links church groups with other medical and
social services in their communities. Using a team of specially
trained nurses, this program provides women with health
assessments to identify diseases for which they may be at risk.
This assessment is followed by a second session in which women
learn about preventive measures they can take to avoid these
conditions, and at the same time, learn about nutrition,
exercise, and stress management techniques.
In order for these programs to continue, there must be an
adequate funding of Medicaid health plans. While Medicaid-
managed care plans are focused intensely on improving health
care for Medicaid enrollees, our efforts are complicated by the
steps States have been taking to limit funding for Medicaid
benefits in recent years.
The American Association of Health Plans and its member
plans are pleased that the centers for Medicare/Medicaid
services has issued regulations upholding the fundamental
principle that Medicaid managed-care plan rates must be
actuarially sound. We believe it is critically important for
CMS to proactively work with the States to be sure these are
implemented in a way that will promote fair and adequate
payments.
We also urge the subcommittee to closely monitor this issue
and ensure that payments to Medicare plans are actuarially
sound.
There is a value to Medicaid-managed care. While payment
adequacy is a major concern for Medicaid-managed care plans, it
is also important for Congress to recognize that plans are
working hard to ensure that State, Medicare-managed programs
receive the highest possible value for the dollars they spend
on health care. Passport, our plan in Kentucky, has saved the
Commonwealth $92.4 million on 100,000 lives in just 4 years,
and our health choices program in Pennsylvania has saved the
Department of Public Welfare hundreds of millions of dollars
since its inception in 1997.
At the same time, enrollees in these programs benefit from
improved continuity of care and are highly satisfied with their
care.
In conclusion, I want to emphasize that AmeriHealth Mercy
and its family of health plans, along with other American
Association of Health Plan member plans, is strongly committed
to our mission of providing high quality affordable patient-
centered care, patient centered health coverage to low income
Americans and persons with disabilities.
We are proud of the success we have demonstrated in
improving the health that is available under Medicaid programs
to many of our Nation's most vulnerable citizens.
In conclusion, I would just like to say thank you for this
opportunity.
[The prepared statement of Daniel J. Hilferty follows:]
Prepared Statement of Daniel J. Hilferty, President and CEO,
AmeriHealth Mercy/Keystone Mercy Health Plan on Behalf of the American
Association of Health Plans
Mr. Chairman and members of the subcommittee, my name is Daniel J.
Hilferty. I am President and CEO of the AmeriHealth Mercy/Keystone
Mercy Health Plan. AmeriHealth Mercy and its family of health plans
serve over 1.3 million Medicaid beneficiaries in six states,
Pennsylvania, New Jersey, Kentucky, South Carolina, Virginia and
California. As a mission-driven organization, AmeriHealth Mercy
specializes in managing the delivery of health care services and
providing health plan management services for organizations serving
enrollees in Medicaid managed care programs and State Children's Health
Insurance Programs (SCHIP).
I appreciate this opportunity to testify about the value that
private sector health plans bring to the Medicaid program. AmeriHealth
Mercy/Keystone Mercy has played a leading role in improving health care
quality for Medicaid beneficiaries. We do this by coordinating care,
placing a strong emphasis on preventive health care services, providing
disease management services for chronically ill patients, and offering
innovative programs to promote the health and well being of our
Medicaid enrollees. We are strongly committed to ensuring that Medicaid
enrollees have access to high quality, affordable, patient-centered
health coverage.
I am also testifying today on behalf of the American Association of
Health Plans (AAHP), of which AmeriHealth Mercy/Keystone Mercy Health
Plan is a member through our parent, Independence Blue Cross of
Pennsylvania. AAHP and its member plans have a longstanding commitment
to Medicaid and its mission of meeting the health care needs of low-
income Americans and persons with disabilities. AAHP's membership
includes approximately 100 health plans participating in Medicaid
managed care programs. In my testimony, I will refer to such plans as
Medicaid managed care plans. Collectively, AAHP members serve more than
half of the 15.5 million Americans who are covered under Medicaid
managed care plans.
Today, I will focus on the strategies Medicaid managed care plans
are implementing to improve the health care system for Medicaid
enrollees. I will begin by reviewing the importance of coordinated care
and why this approach is producing better health outcomes and higher
satisfaction among Medicaid beneficiaries than Medicaid fee-for-service
programs. Next, I will focus on preventive health care services and
disease management programs offered by Medicaid managed care. I will
also highlight several specific examples of the dozens of innovative
programs that plans have developed to meet the needs of their Medicaid
enrollees.
My testimony will also emphasize the importance of ensuring that
state Medicaid managed care programs are funded at levels that support
the participation of Medicaid managed care plans and their providers.
At the same time, I will discuss the important role that plans are
playing in delivering cost-effective health coverage and ensuring that
state Medicaid programs receive maximum value for their limited
resources at a time when state budgets are severely strained.
COORDINATION OF CARE
Medicaid managed care plans have developed systems of coordinated
care for ensuring that Medicaid beneficiaries receive all medically
appropriate health care services, covered under the state Medicaid
managed care program, on a timely basis in a challenging environment in
which an individual's Medicaid eligibility may change during the year.
In general, each Medicaid beneficiary is encouraged to establish a
relationship with a primary care physician who helps makes arrangements
for specialty visits, hospital care, home health care, or other care he
or she may need. The primary care physician ensures that each patient
receives the best available care in the most appropriate setting, and
oversees all of a patient's treatments and medications.
Moreover, coordinated care systems provide for the seamless
delivery of health care services across the continuum of care. In other
words, physician services, hospital care, prescription drugs, and other
health care services are integrated and delivered through an organized
system whose overriding purpose is to prevent illness, improve health
status, and employ best practices to swiftly treat medical conditions
that occur.
This approach is far superior to a system of uncoordinated care in
which patients are forced to navigate a fragmented health care system
on their own. Coordinated care provides the opportunity to reduce
emergency room visits for routine care, and to ensure prompt access to
primary care physicians and specialists when care is needed. It also
promotes communication between treating physicians about various
treatments and medications a patient receives. This is very important
because the interaction of multiple medications prescribed by multiple
physicians can result in high risk to the patient and death in some
instances.
Coordinated care creates an intense focus on health care quality
because health care services are well integrated and a single physician
oversees each patient's care. AmeriHealth Mercy serves a high
percentage of non-traditional Medicaid recipients, the ``sickest of the
sick,'' those accounting for the highest costs (aged, blind and
disabled). AmeriHealth Mercy is at risk for the total cost of care for
the patient/member. Therefore, we have designed a population-based
approach which links traditional medical care management with pharmacy
care management to promote comprehensive, cost effective, quality care.
The results are striking. Our case management programs for high cost
populations have enhanced the quality of life for our members and
produced an annual savings of $740,000 for just 190 high cost members.
Research findings indicate that systems of coordinated care are
highly successful in improving access to health care for Medicaid
enrollees. For example, a study published in the March 2001 issue of
the American Journal of Public Health found that, in New York City,
Medicaid managed care enrollees are more likely than Medicaid fee-for-
service enrollees to have a regular source of health care and also more
likely to obtain care from a doctor's office or a clinic. The same
study found that Medicaid managed care enrollees are less likely than
Medicaid fee-for-service enrollees to obtain care from a hospital
emergency room or an outpatient hospital clinic, which are not optimal
settings for receiving routine care.
PREVENTIVE HEALTH CARE SERVICES
Instead of focusing solely on treating beneficiaries when they are
sick or injured, Medicaid managed care plans place a strong emphasis on
preventive health care services that help to keep beneficiaries
healthy, detect diseases at an early stage, and avoid preventable
illnesses.
According to AAHP's 2001 and 2002 Industry Surveys, Medicaid
managed care plans routinely provide coverage for diabetes screening,
colorectal cancer screening, prostate cancer screening, mammograms for
women age 40 and older, hearing tests for newborns, and osteoporosis
screening. In addition, a large percentage of Medicaid managed care
plans contact enrollees on a regular basis with reminders about child
immunizations, mammograms, cervical cancer screening, or other
preventive services. By actively encouraging enrollees to receive these
services, plans are empowering them to take proactive steps to enhance
their health and well-being.
AAHP's surveys also found that almost all Medicaid managed care
plans offer various types of counseling programs. Many programs focus
on prenatal care, nutrition, or exercise counseling, while others
address issues such as smoking cessation or alcohol dependency. These
programs help enrollees address behavioral or lifestyle issues in ways
that can significantly improve their health and the quality of their
lives.
Medicaid managed care plans also typically exceed the core
objectives of the Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) program by placing a strong emphasis on primary care
for children. The EPSDT programs of Medicaid managed care plans
typically include aggressive education and outreach components in order
to ensure that children receive complete physical examinations, hearing
and vision checkups, dental care, immunizations, and other health care
services they need to stay healthy. One Medicaid managed care plan in
Connecticut has implemented a program that, by using specially trained
staff to place ``welcome'' calls to Medicaid enrollees, was successful
in increasing EPSDT participation rates from 52 percent to 75 percent
in just one year. The delivery of these crucial primary care services
is an important factor in promoting good health among children and
adolescents in the Medicaid program.
Passport Health Plan, owned by University Health Care in Kentucky
and managed by our organization, has improved adolescent immunizations
by over 160 percent from 1997 to 2002, and increased well-child visits
in the first 15 months of life by 216 percent. Over 90 percent of our
pregnant members receive prenatal care meeting the standards of the
National Committee for Quality Assurance from whom Passport has earned
the highest level of accreditation, Excellent in all categories.
DISEASE MANAGEMENT SERVICES
Medicaid managed care plans have also introduced the concept of
disease management programs to Medicaid--improving quality of care for
beneficiaries with chronic conditions by focusing on the comprehensive
care of patients over time, rather than individual episodes of care.
Because of their prevalence, asthma and diabetes are the two illnesses
that are targeted most frequently for disease management services by
Medicaid managed care plans. AAHP's surveys found that the top three
benefits of these services are: (1) reduced morbidity and mortality;
(2) lower health care costs; and (3) improved patient satisfaction.
The success of these programs is demonstrated by research findings
which show that asthmatic children covered by Medicaid managed care
plans are less likely to experience serious asthmatic attacks that
require them to be hospitalized, relative to asthmatic children who
have fee-for-service Medicaid coverage. According to a 2002 report by
the Wisconsin Department of Health and Family Services, 11.7 percent of
asthmatic children in the Medicaid fee-for-service program had asthma-
related hospital admissions, compared to only 8.6 percent of asthmatic
children in Medicaid HMOs.
AmeriHealth Mercy's disease management programs have improved
health outcomes and significantly lowered the cost of care for the
highest cost patients. These programs have achieved major savings and
improved patient care for small, but very ill populations groups. For
example, our Hemophilia Case Management program has reduced
hospitalizations by 40 percent for 60 members, thus saving $2 million
annually in the cost of blood factor and medical care. Our Dialysis
Case Management program saves $2 million annually by improving patient
care for 300 members. Finally, our Sickle Cell Case management program
has reduced hospitalizations by 23 percent and emergency room visits by
24 percent. The savings from high quality Medicaid managed care are
indisputable and the value to members is high.
INNOVATIONS BY MEDICAID HEALTH PLANS
Last year, AAHP published a report highlighting more than 60
initiatives Medicaid managed care plans have undertaken to improve the
health status of Medicaid beneficiaries. This report provides practical
guidance to policymakers and health care professionals on effective
strategies for addressing the needs of Medicaid beneficiaries.
For example, our plan in Pennsylvania, Keystone Mercy, is promoting
preventive health care for its Medicaid enrollees through a Health
Ministry Program for Women. This program links church groups with other
medical and social services in their communities. Using a team of
specially trained nurses, this program provides women with health
assessments to identify diseases for which they may be at risk. This
assessment is followed by a second session in which women learn about
preventive measures they can take to avoid these conditions and, at the
same time, learn about nutrition, exercise, and stress management
techniques.
Another AAHP member plan, Humana, has implemented a program in both
Florida and Illinois to improve patient care for pregnant Medicaid
enrollees. Under this program, the health plan first takes steps to
identify women who are at risk of experiencing complications during
their pregnancies. Obstetrical case managers then perform ongoing
assessments of these women and coordinate the care they receive from
their primary care physicians and other health care professionals.
Educational materials, including a pregnancy-related guidebook, are a
key component of this program. A survey found that 99 percent of
participants were satisfied with this program.
Another excellent example is an asthma program that an AAHP member
plan, UCare Minnesota, implemented in Minnesota in 2000. This program
provides Medicaid beneficiaries who have asthma with an ``action
plan''--developed by their primary care physicians--with specific
directions on steps to take when a patient's asthma reaches certain
levels of severity. In addition, this program makes arrangements for
respiratory nurses to conduct home health visits during which they
educate patients about the proper use of their inhalers and peak flow
meters. Patients can also reach respiratory nurses through a telephone
hotline that is open 24 hours a day, seven day a week. A survey of
patients participating in this program found that 97.1 percent were
satisfied with their action plan and 98.8 percent were satisfied with
their nurses.
The Medicaid populations we serve are unique. Our PerformRx
program, an in-sourced pharmacy management program, has applied our 20
years of experience in Medicaid care management to achieve an 8.8
percent average annual pharmacy trend, versus the national trend of 20
percent. Remember, this is for the sickest, most disadvantaged
citizens!
ADEQUACY OF MEDICAID HEALTH PLAN PAYMENTS
While Medicaid managed care plans are focused intensely on
improving health care for Medicaid enrollees all across the nation, our
efforts are complicated by the steps states have been taking, in
response to budget crises, to limit funding for Medicaid benefits in
recent years. According to a September 2003 report by the Kaiser Family
Foundation, 21 states either reduced or froze Medicaid managed care
payments in fiscal year 2003, and 19 states are targeting Medicaid
managed care for similar payment cuts or freezes in fiscal year 2004.
These cost containment measures are seriously challenging the viability
of Medicaid managed care program participation for plans that are
demonstrating their strong commitment to providing Medicaid
beneficiaries with the high quality health coverage they need and
deserve.
AAHP and its member plans have strongly encouraged the Centers for
Medicare and Medicaid Services (CMS) to take appropriate steps to
ensure that state Medicaid agencies provide adequate funding for plans
serving Medicaid enrollees and their providers. We are pleased that the
agency has issued regulations and related guidance upholding the
fundamental principle that Medicaid managed care payment rates must be
actuarially sound.
We believe it is critically important for CMS to proactively work
with the states to ensure that these regulations are implemented in a
way that promotes fair payments to support the continued viability of
Medicaid managed care programs. We also urge the subcommittee to
closely monitor this issue and take any steps that may be needed to
ensure that payments to Medicaid managed care plans are actuarially
sound.
VALUE OF MEDICAID MANAGED CARE
While payment adequacy is a major concern for Medicaid managed care
plans and their enrollees and providers, it is also important for
Congress to recognize that plans are working hard to ensure that state
Medicaid managed care programs receive the highest possible value for
the dollars they spend on health care. In addition to delivering high
quality health coverage, health plans also bring value to the Medicaid
program by providing coverage that is much more cost-effective than
fee-for-service Medicaid coverage.
One recent study, conducted by the Lewin Group, found that pharmacy
benefits are 10 to 15 percent less costly under Medicaid managed care
programs, compared to Medicaid fee-for-service programs. This is a
highly significant finding, considering that rapidly rising
prescription drug costs are a major factor contributing to medical
inflation throughout the health care system.
Another study, conducted by Milliman USA, Inc., estimated that
Medicaid managed care plans saved the Wisconsin Medicaid and BadgerCare
programs a total of $35 million in 2001 and $56 million in 2002. This
study indicated that health plans did a better job, relative to the
Medicaid fee-for-service system, of reducing the inappropriate use of
emergency rooms and unnecessary inpatient hospital stays. Moreover,
this study found that Medicaid health plan enrollees in Wisconsin are
more highly satisfied than Medicaid fee-for-service enrollees.
Yet another study, conducted by Schaller Anderson, found that
managed care plans in Oklahoma's Medicaid program achieved savings of
four percent in the total medical and administrative costs associated
with health care for persons with chronic disabilities. This same study
found that 61 percent of Medicaid managed care enrollees with chronic
disabilities said their care was better than under the Medicaid fee-
for-service program; another 32 percent said their care was about the
same. Fully 60 percent of these beneficiaries said it was easier to get
prescription drugs through their health plan than through the fee-for-
service program.
Passport, our plan in Kentucky, has saved the Commonwealth $92.4
million on 100,000 lives in just four years and our HealthChoices
program in Pennsylvania has saved the Department of Public Welfare
hundreds of millions of dollars since its inception in 1997. At the
same time, enrollees in these programs benefit from improved continuity
of care and are highly satisfied with their care.
CONCLUSION
In conclusion, I want to emphasize that AmeriHealth Mercy and its
family of health plans, along with other AAHP member plans, is strongly
committed to our mission of providing high quality, affordable,
patient-centered health coverage to low-income Americans and persons
with disabilities. We are proud of the success we have demonstrated in
improving the health care that is available under Medicaid programs to
many of our nation's most vulnerable citizens.
By coordinating care, by emphasizing prevention, by offering
disease management services to the chronically ill, and by developing
innovative programs to meet the unique needs and circumstances of our
Medicaid enrollees, we have established ourselves as a model for
Congress to consider as you address the challenges in Medicaid--
including the current funding crisis--and undertake future efforts to
expand coverage to the uninsured.
Mr. Bilirakis. Thank you so very much, sir.
Dr. Medows, you are on.
STATEMENT OF RHONDA MEDOWS
Ms. Medows. Good morning, Chairman Bilirakis,
Representative Brown, Representative Wilson, Representative
Green.
I want to thank you for the opportunity to address with you
today the role of disease management in Medicaid programs, as
well as improving clinical outcomes. I am Dr. Rhonda Medows, I
am a family physician, and also the Secretary of Florida's
Agency for Health Care Administration. That is the State's
agency that administers the Medicaid program as well as
regulates health-care facilities and HMO's.
Today I would like to share with you some highlights of our
innovative programs that are in the State of Florida, as well
as some lessons learned as we have trudged through implementing
disease management programs over the years.
By way of history, you may recall that Governor Bush, in
his recent testimony, stated that Florida is the fourth in the
Nation, in terms of the size of its Medicaid program. We serve
2.2 million people and have a $12.7 billion budget.
On further review of the health care expenditures that are
covered in that budget, we noted that 50 percent of our health
care expenditures were associated with only 5 percent of our
population. On further review, we noted that 5 percent of the
population had in common several chronic illnesses. Disease
management has allowed us to address those chronic disease
States, as well as those in need of beneficiaries more
directly. So since 1997, Florida became one of the first States
in the Nation to implement disease measured programs as a way
of addressing those needs. To date, we have disease-measured
programs for individuals with diabetes, hypertension,
congestive heart failure, asthma, all the immune diseases, HIV
AIDS, hemophilia and depression.
The goals for disease management for us include four major
categories. One is that we want to be able to change the
behavior of the beneficiary, and by changing the behavior, I
mean, to increase their compliance with their treatment
regimen, to get them to understand what their disease consists
of and how they can best control it.
We encourage medication compliance, lifestyle changes, such
as correct diet, weight loss, smoking cessation, home
monitoring of blood pressures, and also glucose monitoring for
those with diabetes.
The second goal is to improve the quality of care that is
delivered, and this is best noted when we see that we through
disease management actually coordinate their care better,
coordination between the patient and physician, as well as
between the primary-care physicians and specialists and other
health-care professionals.
We also, through disease management, have the opportunity
to share best practices and use those across the State.
Third goal would be to improve health outcomes. Well, if
one and two happen, then our third bullet actually comes to
play, but in addition to improving the quality of care and
changing behaviors, we also want to make sure we empower the
beneficiary to assume the ability to make their wise health
care decisions, so therefore, we invest in their education, the
resources they need, and support their need to make those
correct health care decisions; and our fourth goal is to lower
health care expenditures. This comes about when they are able
to make again the correct health care decisions. We note that
this occurs when they are taught about the appropriateness of
ER visits, the use of hospitals for care.
We teach them how to do preventive care, how to do
maintenance care, instead of focusing on crisis care or acute
care, which have been the previous model.
We also look at the expenditures in terms of not just the
dollar amount saved by looking at claims, but also in terms of
the quality of life and quality of health that they develop
with these changes.
We use measures that are evaluated by independent
evaluators to try and keep this as scientifically sound as
possible.
I would like to share with you some lessons learned, and
there is probably a whole book that we could probably go
through, but I will try to condense it down to maybe five basic
ones. No. 1, disease management is an investment in people. The
return on this investment is not one that you should think is
going to be immediate. We are talking about a long-term
investment that takes years to develop.
In the short-term, what happens is we enjoy the benefit of
people making lifestyle changes. We enjoy watching the
improvements in clinical outcomes as they develop. We enjoy the
benefit of having emergency room visits decline and
hospitalizations decline as people learn to take better care of
themselves and invest in themselves up front.
Second, we have learned the value of public private
partnerships. At a time when our State budgets are very well
constrained, we have learned to look outward into the community
and into the private sector to partner with us in the
development of these programs.
Our third lesson learned that I would share with you is
that we have learned to look at the whole person, and when I
say this, I mean that our first disease management program
focuses primarily on a specific disease state that an
individual had and providing them with specific services to
address that one disease. In reality, though, many of our
beneficiaries actually have multiple diseases. They have co-
morbidities.
To be more realistic in our approach to try and improve
their health outcomes, we had to address their multiple co-
morbidities. It is difficult to treat someone with asthma,
prescribe medication and not take into account that they also
have diabetes as well, that the medication we prescribe for
asthma does not affect their diabetes. It does. It needs to be
taken into account, and on that note I can say that one of our
prime examples of being able to address the person as a whole
and to look at co-morbidities is the Florida Healthy State
program. This is the program that we have developed in
partnership with Pfizer, so this is our public private
partnership.
In it, we address the needs of people who have asthma,
hypertension, diabetes and congestive heart failure. Pfizer
provided a grant for the disease management program for its
development and for its operations. The Agency for Health Care
Administration used this money and funding to contract with 10
of our high-volume safety net hospitals scattered about the
State.
In addition, I should note that it is not just a
partnership with the hospital, but it is with the medical
community that is associated with that hospital.
In addition, we also had contracted with the call center to
provide additional support services. This created a community-
based network of care statewide.
The components of the Florida Healthy State program include
the following: No. 1, 60 care managers. These are nurses who
are individually assigned to individual beneficiaries, usually
those who are higher at risk for any of the four diseases that
I have described to you and we have 13,000 individuals who are
assigned to a particular nurse who is available to them, not
just on phone. I do not want to shock you, but occasionally
home visits do occur.
No. 2, there is a 24/7 call center that is available to all
participants in this program. At the call center there are
medical professionals and health-care professionals available,
whether they be nurses, nutritionists, et cetera . They are
able to provide education, and let's just say gentle
encouragement to the individual to take care of themselves,
complete their compliance as required.
Mr. Bilirakis. Please try to summarize, Doctor.
Ms. Medows. I am going to try to wrap this up real quick.
The program also consists with providing them with the home
health care supplies they need to manage their disease. It
provides health literacy. It is both culturally and
linguistically appropriate, as well as a different literacy
levels, as well as product donation. The program has reached
113,000 individuals. The fourth and final lesson that I will go
over with you today is that the disease management program we
believe needs to be community-based. We believe that the
services should be delivered where the beneficiary lives.
Through a partnership with Bristol Myers Pharmaceutical
Company, we have a program that is community-based. It utilizes
the 27 fully health care qualified centers in the State and
seven counties, and what it does is it incorporates the value
of lay health care leaders who are already in the communities,
some of which are faith-based, and it is primarily directed
toward minority communities, Hispanics, African Americans, et
cetera, and what we do is pair them up with health-care
professionals, who can take the information back into the
community for education support, particularly on issues such as
diabetes and depression. Those would probably be the major
lessons learned.
In conclusion, I would like to say that we are seeing
through our programs, both the ones that I mentioned and the
many other others that we have, that there is improved
lifestyle changes, there is improved behavior in terms of
making correct health care decisions. There is a decline in the
use of ER visits, as well as inpatient hospitalizations.
We believe that disease management is a potentially
powerful tool in managing health, as well as health care costs.
Thank you. I appreciate the time.
[The prepared statement of Rhonda Medows follows:]
Prepared Statement of Rhonda Medows, Secretary, Florida Agency for
Health Care Administration
Good Morning, Chairman Bilirakis, Representative Brown, and Members
of the Committee. Thank you for this opportunity to address the
Committee on improving quality and clinical outcomes through disease
management in the Medicaid program. I am Dr. Rhonda Medows, Secretary
for Florida's Agency for Health Care Administration (AHCA)--the state
agency that directly oversees the Medicaid program. Today, I will
briefly highlight a number of innovative Medicaid disease management
programs in Florida.
As you learned from the testimony of Governor Bush earlier this
year, Florida's Medicaid program is the nation's fourth largest. We
serve more than two million people and manage a $12.7 billion budget.
Disease management in Florida is a pioneering effort to coordinate
treatment efforts and improve health outcomes. We established a number
of unique programs that are financed through innovative strategies--
including pharmaceutical investments, and other state partnerships.
They focus on chronic diseases, the area that accounts for one of the
largest portions of Medicaid spending. We spend 50 percent of our
Medicaid budget on 5 percent of our beneficiaries.
In 1997, Florida Medicaid was one of the first state Medicaid
programs to establish a disease management program, and may, today,
have the largest Medicaid initiative in the U.S. We have learned a
great deal about what works and what does not. Time is needed to
realize the full benefits of disease management, but early outcomes are
positive and worth noting.
This is what we know(disease management works. It saves dollars.
For a three-year period starting in July 2000, it is estimated that
through program savings and manufacturer guarantees, federal and state
Medicaid program spending has been reduced by nearly $90 million. And,
more importantly it has led to changes in health behaviors, better
health outcomes, and improved quality of care and life. We have seen
individuals lose weight, start exercising, and check their blood
pressure and blood sugar on a daily basis. Many have returned to more
active lifestyles, allowing some to return to work.
In Florida, we started with a demonstration project and have now
implemented disease management programs for asthma, autoimmune
disorders, congestive heart failure, diabetes, hemophilia, HIV/AIDS,
hypertension, and depression.
Our goals have been to educate consumers, promote best practices,
improve health outcomes and care coordination, and reduce both
emergency room visits and inpatient hospitalizations. Our first efforts
were segmented. That is, we assigned beneficiaries to specific
interventions targeted for specific diseases. We quickly found that
significant numbers of beneficiaries had more than one chronic
condition. This led us to change the program to address patients with
multiple diseases. We adjusted our focus to caring for the total
patient, not just the diseases.
DISEASE MANAGEMENT PROGRAMS
Beneficiary education and consultation has been a primary focus of
the GlaxoSmithKline program as they have provided funding through a
medication error demonstration project. AstraZeneca has funded outreach
to physicians through regional pharmacists.
The first effort to serve patients with multiple diseases was
through our partnership with Pfizer, Inc., to serve people with asthma,
congestive heart failure, diabetes, and hypertension. Pfizer provided a
grant for disease management services, and the Agency contracted with
10 high-volume hospital systems and one call center. Patients are
matched with 60 nurse care mangers to provide one-on-one beneficiary
education and to support change in health behavior. The program
expanded--doubling from the original 50,000 targeted population--to
more than 113,000 beneficiaries enrolled in this disease management
program.
Participants work individually with their nurse care managers who
assess their physical, mental and environmental status, provide
education about their diseases, support healthy behavior changes,
coordinate care with primary care providers and specialists, and help
with access to other needed services. The process empowers people. It
helps them make better health care choices and navigate the health care
system more efficiently. It provides help with managing the conditions
at home by offering glucometers and lancets for diabetics, pillow
covers and peak flow meters for asthmatics and weight scales and blood
pressure cuffs for heart failure patients at no charge to either the
beneficiary or Medicaid.
With Bristol-Myers Squibb we launched a second partnership to
provide disease management services through a contract with Federally
Qualified Health Centers in seven counties. For the first time we
employed a faith based outreach model using Promotoras (lay health
workers) with health professionals, and social workers to provide
education and support for a minority population with diabetes and
depression. More than 2,100 minority beneficiaries have been enrolled.
These partnerships offer a new funding model financed by
pharmaceutical manufacturers through a combination of investments and
guaranteed savings. Service delivery is focused in the communities
where beneficiaries live and requires daily involvement by participants
toward a goal of improving both their overall health and their quality
of life.
Let me provide an example. Cora Stewart is a 62-year-old Miami
woman with diabetes, hypertension, congestive heart failure and
emphysema. Before enrolling in disease management under the Pfizer
grant, she was insulin dependent, had high cholesterol and could not
walk a block or climb stairs. Working with her nurse care manager, Cora
lost 45 pounds in six months. She began monitoring her blood pressure
at home. She recently attended her daughter's wedding--without the
walker she has relied on for years. She has taken control of illnesses
that previously controlled her life.
These disease management programs have reduced inpatient
hospitalizations and the number of emergency room visits, brought a new
level of coordination to every participant's total health care, and
improved their quality of life immeasurably. And as if those outcomes
were not enough, we have realized substantial cost savings.
Disease management is a powerful tool both in managing health and
in containing Medicaid costs. This common sense approach is emerging as
the next important chapter in health care.
Thank you. I will be happy to answer any questions you may have.
Mr. Bilirakis. Thank you, Doctor.
Mr. Simms.
STATEMENT OF JEFFREY SIMMS
Mr. Simms. Good morning, Mr. Chairman, and other members of
the subcommittee.
I am Jeffrey Simms, one of the assistant directors of the
State Medicaid program for North Carolina, and thanks for the
opportunity to share our experience with you.
Over the last 10 years, the North Carolina Department of
Health and Human Services, through its two agencies, the
Division of Medical Assistance and the Office of Research
Demonstrations and Rural Health Development, has worked
diligently to link Medicaid recipients with the primary care
provider and create medical homes across the State.
This link with the provider has enabled us to really
establish a system where we can have the infrastructure to
buildupon to improve the health care for the Medicaid patients
in North Carolina.
As of October 1, 2003, we have more than 700,000 Medicaid
recipients linked with the primary provider and in the medical
home across the State. 417,000 of those 700,000 recipients are
enrolled with providers who are participating in what we call
community care of North Carolina, where we are able to have
disease management and other quality improvement conditions in
place for them.
The Community Care of North Carolina program has
established a structure that allows the local, State coalition
of county, which includes primary care providers, health
departments, hospitals and departments of Social Services to
partner together and create a local health care delivery system
for the Medicaid patients receiving care.
The local CCM networks identify costly patient services and
then develop strategies which will improve utilization and cost
management.
The local community care networks collaborate at the State
level through statewide clinical directors groups, which select
targeted disease and care management processes which will be
implemented systematically in all networks. They also review
evidence-based practice guidelines and establish program
measures.
Disease management in North Carolina has been implemented
for diseases specific to asthma and diabetes, and these
initiatives include process measures like chart audits, whereby
the State and local networks can measure the providers
performance and offer feedback regarding this process measure.
Since the implementation of the asthma initiative over the
last 4 years, we have seen a continual increase in the number
of individuals who suffer from asthma who are appropriately
staged or documented for staging, given the appropriate
prescription for corticosteroids and accurate asthma action
plans in their medical records.
Improvement can also be seen in the areas of
hospitalizations and emergency room utilization for children
who suffer from asthma.
For the period of April 2000 through December 2002, the
rate of inpatient hospitalizations for children who were linked
with the CCNC doctor is 5.3 per 1,000 member months in
comparison to 8.2 per 1,000 member months for individuals who
were not linked with CCNC providers.
Overall cost data shows that for calendar year 2000, the
average asthma episode cost is was $687 for children who were
linked with the CCNC provider and the cost for children not
linked with the CCNC provider was $857 for the episode.
Through the CCNC program, we are able to identify patients
who use the emergency room frequently for what would be
classified as routine primary care and the care managers follow
up with the patients on the telephone, reminding him of primary
telephone care office hours, after hours telephone numbers, and
they also do home visits as well.
We are seeing the benefits of these efforts, but we are
limited in the steps that can be taken to control the
inappropriate use of the emergency room because of certain
regulations.
During the period of July 1, 2001 to June 30, 2002 we were
able to show somewhere in the neighborhood of a 6 percent
difference in emergency room utilization for the individuals
and children linked with CCNC providers.
The CCNC infrastructure at the local level affords us the
opportunity to work with the local hospitals to devise
strategies to reinforce the medical home concept and to also
provide the patient's primary care providers with real time
emergency room encounter sheets.
That is where the local partnership with the local hospital
helps us and is able to come to the table to work with us.
We are also exploring reimbursement options for the
emergency room as well. The providers who are participating in
community care of North Carolina have seen this, as the
opportunity to really work together and identify ways and
strategies to improve care, but not only improve care and
quality, but also figure out ways to address some of the budget
issues we are facing with our North Carolina Medicaid program.
They identify strategies that would give us quick return.
One of those is by looking at prescribing patterns for the
providers participating in the community care of North
Carolina. As a result, the providers have come together and
they have developed a voluntary provider list where they are
able to go in and look at prescribed drugs that evaluate the
relative cost of medicines prescribed to key therapeutic
categories.
They identify the top 100 drugs by Medicaid expenditures in
North Carolina, and then arrange those compounds in a tiered
fashion, whereas the providers are now able to see where the
actual costs are.
As a result of this voluntary provider-driven effort,
preliminary findings show that a post-rollout period of
February through March of 2003 has shown 22 percent lower
expenditures compared to pre-rollout period of September
through October of 2002.
Additionally, the Community Care of North Carolina
infrastructure has allowed us to develop and implement
strategies that are not necessarily included in the traditional
PCCN program. We have looked at a nursing home polypharmacy
initiative that creates pharmacist and physician teams that
review drug profiles and medical records and care coordination
for Medicaid patients and nursing homes.
They determine if a drug therapy problem exists and
recommend a change and perform follow-up. Approximately 9,200
nursing home residents had greater than 18 drugs used within a
ninety-day period. The criteria used to identify individuals
included inappropriate drugs for the elderly, known as Beers
drugs, drugs used beyond usual time limits, drug use warning
and precautions and potential therapy duplications.
We have been able to see some results of that initiative in
the UNC School of Pharmacy, is completing an extensive
evaluation of this initiative.
In my conclusion, the Community Care of North Carolina
program provides the infrastructure for the Department of
Health and Human Services and the Medicare program of North
Carolina to set priorities that can be implemented at the local
level. We will continue to identify additional disease
management initiatives and other opportunities for
coordination, which will allow us to collaborate with public
providers--public and private providers at the local level.
We have learned that the success of this program is
contingent on community ownership, partnership, appropriately
aligned incentives, behavior change and the ability to measure
change and patients.
Thank you.
[The prepared statement of Jeffrey Simms follows:]
Prepared Statement of Jeffrey Simms, Assistant Director, North Carolina
Division of Medical Assistance
Over the last ten years, the North Carolina Department of Health
and Human Services through two of its agencies--the Division of Medical
Assistance and the Office of Research Demonstrations and Rural Health
Development, has worked diligently to link Medicaid recipients with a
primary care provider in their local community, creating a medical home
and addressing the access to medical services issue commonly known to
Medicaid recipients. This link with the provider has established the
basic infrastructure of the Community Care of North Carolina Program,
also known as Carolina ACCESS I, II & III, a statewide primary care
case management program. Community Care of North Carolina provides a
system wherein the health care for the Medicaid population can be
managed through a fee for service reimbursement environment.
As of October 1, 2003 more than 700,000 Medicaid recipients across
the state have medical homes with providers through this PCCM program
and approximately 417,000 of these recipients are linked with one of
the 2,000 providers who participate in a Community Care Provider
Network that focuses on improved quality, utilization and cost
effectiveness for the Medicaid program. Included in the supporting
information is a map showing the distribution of the current thirteen
CCNC networks across North Carolina. We are in the process of expanding
the CCNC networks statewide by June 30, 2005.
The Community Care of NC Program has established a structure that
allows the local stakeholders in a county, which includes primary care
providers, health departments, hospitals, and Departments of Social
Services, to partner together and create a local health care delivery
system for the Medicaid recipients receiving care in their community.
The local CCNC networks identify costly Medicaid patients and services
and then develop strategies that will improve utilization and cost
management. This local collaboration also assists in the elimination of
the fragmentation of care between public and private providers.
The local Community Care Networks collaborate at the state level
through the statewide clinical directors group, which selects targeted
disease and care management processes that will be implemented
systematically in all networks; reviews evidenced-based practice
guidelines; and establishes program measures. At the present time these
targeted disease and care management processes include: asthma,
diabetes, pharmacy management, high risk/high cost management, and
emergency room utilization.
Any of the disease management initiatives implemented in Community
Care of NC involves the clinical directors group setting performance
standards; each network obtaining local provider buy-in; standardized
physician toolkits; local and state level technical assistance; and
practice level quality improvement system processes.
The asthma and diabetes disease management initiatives include
chart audits as a process measure whereby the state and networks can
measure the providers' performance and offer feedback regarding this
process measure. Since the implementation of the asthma initiative over
the last four years we have seen a continual increase in the number of
individuals who suffer from asthma who had documentation of staging,
appropriately prescribed corticosteroids and accurate asthma action
plans in the medical record. A bar graph is included in the packet
showing this trend. Also included is a graph showing the chart audits
for diabetes, which also shows improvements in the way providers are
treating individuals who suffer from diabetes.
Improvement can also be seen in the area of hospitalizations and
emergency room utilization for children who suffer from asthma. For the
period of April 2000-December 2002, the rate of inpatient
hospitalizations for children linked with a CCNC provider was 5.3 per
1000 member months, whereas those children linked with providers who
were not participating in CCNC was 8.2 per 1000 member months.
For that same period, April 2000 through December 2002, the
pediatric asthma emergency room utilization rate was 158 per 1000
member months for children linked with a CCNC provider, whereas for
children linked with providers who were not participating in CCNC, the
rate was 242 per 1000 member months.
Overall cost data shows that for calendar year 2000, the average
asthma episode cost was $687 for children under 18 years of age linked
with a CCNC provider and the cost for those children linked with a
provider who was not participating in CCNC was $857. We are in the
process of pulling more recent cost data related to the treatment of
asthma.
CCNC has enabled the North Carolina Medicaid program to establish
medical homes for the Medicaid population across the state. However, we
still struggle with the inappropriate use of the emergency room.
Through the CCNC program we are able to identify patients who use the
emergency room for what would be classified as routine primary care and
the care managers follow up with those patients on the telephone,
reminding them of their primary care provider's office hours and after
hours telephone number. We are seeing the benefits of these efforts,
but we are limited in the steps that can be taken to control the
inappropriate use of the emergency room. During the period of July 1,
2001 through June 30, 2002, we were able to show a 6% difference in the
number of children linked with a CCNC provider who received services in
the emergency room when compared to the children linked with a provider
who was not participating in CCNC. The CCNC infrastructure at the local
level affords us the opportunity to work with the local hospitals to
devise strategies to re-enforce the medical home concept and to also
provide the patient's primary care providers with real time emergency
room encounter sheets. We are also exploring reimbursement options for
the emergency room.
The physicians who participate in Community Care of North Carolina
felt the need to encourage providers to take an informed look at their
prescribing habits for their Medicaid patients. The providers felt the
need to evaluate the relative costs of medicines prescribed in key
therapeutic categories. They identified the top 100 drugs by Medicaid
expenditures in North Carolina and then arranged those compounds in a
tiered fashion by average wholesale price (AWP), where Tier 1 drugs
offer the greatest potential cost savings to the Medicaid program. The
tiered list is shared with providers throughout the CCNC network via
posters, pocket-sized reference cards and an electronic drug reference
entitled ePocrates. As a result of this voluntary, provider driven
effort, preliminary findings show that a post-rollout period of
February-March 2003 has a 22% lower expenditures compared to a pre-
rollout period of September 2002-October 2002. The actual savings
equals approximately $640,000.
Additionally, the CCNC infrastructure has allowed us to develop and
implement a nursing home poly-pharmacy initiative that creates
pharmacist and physician teams that review drug profiles and medical
records for Medicaid patients in nursing homes. They determine if a
drug therapy problem exists and then recommend a change and perform
follow-up. Approximately, 9,208 nursing home residents had greater than
18 drugs used within a 90 day period. The criteria used to identify the
individuals included: inappropriate drugs for the elderly known as
``Beers drugs''; drugs used beyond usual time limit; drug use warnings
and precautions; the prescription advantage list; and potential
therapeutic duplication. Of the 9,208 patients, recommendations were
made on 8,559 of them and 74% or 6,359 had recommendations implemented.
This initiative has proven that the pharmacist and physician team
approach reduces costs and improves quality. The UNC School of Pharmacy
is completing the evaluation of this initiative. Potential expansion
options include all nursing home and assisted living patients,
including adult care home patients in North Carolina.
In my conclusion the Community Care of North Carolina program
provides the infrastructure for the NC Department of Health and Human
Services to set priorities that can be implemented at the local level.
We will continue to identify disease management initiatives and other
opportunities to collaborate with public providers at the local level.
We have learned that the success of this program is contingent upon
community ownership, partnership, appropriately aligned incentives,
behavior change, the ability to measure change and patience.
Mr. Bilirakis. Thank you very much, Mr. Simms.
Ms. Bella, you are on.
STATEMENT OF MELANIE M. BELLA
Ms. Bella. Good morning, Mr. Chairman, Representative
Brown, Representative Wilson and Representative Green.
My name is Melanie Bella. I am the Medicaid director for
the State of Indiana, and I appreciate the opportunity to come
talk to you a little bit about what we are doing.
Under the leadership of our Governor, Joe Kernan, and in
partnership with our State Department of Health and the Health
Commissioner, Dr. Wilson, we have developed what we call the
Indiana Chronic Disease Management program. It is a program
that is designed to change the way care is delivered statewide,
not just within the Medicaid population, because the problems
that we see plaguing our programs in the area of chronic
disease are the same ones that our Medicare beneficiaries are
facing, our employers are facing, and the rest of the public
health community providers in Indiana are facing, so it is
critical that we have the partnership of the Department of
Health in building this community effort that we have put
together.
Right now, we started our program in July and we have a
program in place for recipients place for diabetes and
recipients with congestive heart failure and we will be adding
asthma, stroke, hypertension, HIV AIDS within the next 6-month
period, so we are excited about the initial results we are
seeing, and I want to talk to you a little bit about how we got
to where we are.
We started out looking at using commercial disease
management vendors and changed the course to really do what we
call assemble the pieces in a locally based infrastructure
across the State that utilizes our existing public health
infrastructure and puts together a program that works for the
State, regardless of payer source, regardless of disease state,
to create true sustainable long-term value for the State of
Indiana.
Henceforth, our focus has been on developing infrastructure
that we need to promote permanent, long-term, sustainable
change, so if I could just direct you to that picture over
there for a few minutes and hopefully keep me on time here.
I want to talk to you about the main pieces that are part
of our program and how they work together, and there are five
main principles that we have used in putting together this
infrastructure, those being what we promote as evidence-based
guidelines, protocols for our providers. We believe strongly
that this program must have the involvement of patients and we
have a strong patient self-management program, we use the
Stanford self-management approach.
We would not be able to do this program without extensive
involvement by the primary care providers in the Indiana
community.
Fourth, this program must be cost effective for us. As you
all know, the pressures that Medicare and payers everywhere are
facing, and last it is very important that we use our existing
public health infrastructure. If we are going to spend
resources on attacking the problems of chronic illness, we
wanted to spend those in-state and infuse them into the local
public health infrastructure, rather than spend them quite
honestly with a commercial vendor, so let me talk to you about
those pieces.
If you start at the top, that is where Medicaid and the
Department of Health are working together and using community
resources, and that feeds really into the heart of our program,
which is the patient and the provider.
The goal of this program is to keep the patient engaged
with their medical home, knowing if we are going to have long-
term sustainable success the patient has to be engaged with
their primary-care provider. We provide a support system, but
that is just short-term, dead-end work with our high-needs
patients and put them back in touch with their primary-care
system to promote the medical home concept.
On the left-hand side is where we bring in the patient, and
we are teaching them self-management, how to better interact
with their primary care providers and make healthy choices and
decisions affecting their health care.
On the right-hand side are the materials and tools that we
give to our providers. We were fortunate enough to be kind of
adopted by the McCall Institute and use the chronic care model
and the institute for Health Care Improvement to help us take
evidence-based guidelines, work with our physician, community,
and commercial payers within the State to modify them for
Indiana's use and put together guidelines and protocols that
have been endorsed by payers and providers to spread across the
State so that everyone in Indiana is using the same evidence-
based guidelines for these disease states, so it is those
resources that we feed into our providers.
I brought a copy today. We have a provider tool kit and a
nurse care manager book, very simple, straightforward
guidelines, flow sheets. I would be happy to share this with
anyone.
In addition, we have all of this on CD that we have
provided to all of our providers who are interested across the
State and who are also willing to share with any other State
Medicaid programs or public health entities, because this has
been developed in the public domain and we want to maximize the
public investment for everyone.
Mr. Bilirakis. Would you provide those to the committee?
Ms. Bella. Certainly. I will be happy to do that.
Mr. Bilirakis. Without objection, that will be the case and
that will be made part of the record.
Ms. Bella. Okay.
Thank you very much.
Again focusing on the heart of the patient and provider,
the question was what supports do we give to promote the
medical home concept, so we have a care management component
that has two pieces: One is a call center and one is a network
of care managers.
Our call center is managing about 80 percent of our
patients, although they touch everyone in our program and our
call center functionality is provided with our existing partner
who provides call center services to Medicaid. That helps us,
because they already know our population and they have
credibility with our provider base.
We have a nurse care manager network that those functions
are provided to us by Indiana Minority Health Coalition and our
primary health care association; again, resources already
located in the community who know how to deal with our patient
population.
And last and most importantly, we have a Web-based patient
registry that we developed in conjunction with one of the
Medicare quality improvement organizations to support the
exchange of data and the ability to measure outcomes, and we--I
know I am running out of time, but I would be remiss not to let
you know that we have a very strong measurement and evaluation
component in place that is being provided to us by the
Regenstrief Institute of the Indiana University School of
Medicine. They will be doing a statewide study of our program,
as well as a randomized controlled trial, so that we can truly
isolate the impact of these interventions and see if what we
are doing is successful or not, so I would very much appreciate
the opportunity to talk to you today and would love to share
information with anyone who is interested in how to change the
way care is delivered across their State.
Thank you very much.
[The prepared statement of Melanie M. Bella follows:]
Prepared Statement of Melanie M. Bella, Assistant Secretary, Indiana
Family and Social Services Administration
INTRODUCTION
Chairman Bilirakis, Ranking Member Brown, distinguished
Subcommittee members, thank you for this opportunity to share with you
an initiative designed to improve quality and clinical outcomes for
Medicaid recipients in Indiana. My name is Melanie Bella, and I am the
Assistant Secretary of the Indiana Family and Social Services
Administration, and the Director of the Office of Medicaid Policy and
Planning (OMPP). In partnership with the Indiana State Department of
Health and the State Health Commissioner, Greg Wilson, M.D., we have
developed and implemented a comprehensive initiative, the Indiana
Chronic Disease Management Program (ICDMP), designed to change the way
health care is delivered across the state of Indiana.
The goal of the ICDMP is to build a comprehensive, locally based
infrastructure that: 1.) is sustainable; 2.) strengthens the existing
public health infrastructure; and 3.) helps improve the quality of
health care for all populations, not just Medicaid recipients. We hope
that the ICDMP infrastructure will be an asset not only for patients
but also for healthcare providers. We also hope the ICDMP can serve as
a model for other states that may be interested in building integrated,
locally based infrastructures for their Medicaid program and state as a
whole. Strengthening public health systems and care delivery networks
designed to decrease the prevalence of chronic illness and increase the
use of primary care ensures that states are maximizing the public
investment in achieving quality health outcomes.
MEDICAID CHALLENGE
The Medicaid program in Indiana covers approximately 765,000
recipients at a cost of $4.3 billion today. Like most states,
enrollment and demand for Medicaid services continues to increase. By
the end of State Fiscal Year 2005, Indiana expects to spend $4.8
billion to cover over 825,000 recipients. Even with continued cost
containment efforts, the rates of growth in Medicaid expenditures will
continue to be unsustainable for states unless they develop new
strategies for managing Medicaid costs. The new strategies must address
the primary drivers of Medicaid expenditures: utilization and poor
quality. It is critical that Medicaid programs focus on controlling
utilization and improving health care quality for recipients with
chronic illness. By making strategic system investments, states can
develop the infrastructure necessary to improve care delivery and
quality outcomes, which will help chronically ill patients lead more
productive lives, slow the rate of growth in the short term and,
ultimately, reduce costs in the long term.
BACKGROUND
In 2000, approximately 125 million people in the United States had
some type of chronic illness and by 2020 it is estimated to grow to 157
million. By 2010, 17% of our GDP will be spent on health care, and 78%
of these costs will result from chronic diseases, including almost 80%
of total Medicaid expenditures, and this is increasing as our
population ages. Numerous surveys and audits have documented gaps
between well-established guidelines for the clinical aspects of care
and how practitioners are actually delivering care. Providers feel
resource constrained and too rushed to meet the clinical, educational,
and psychological needs of chronically ill patients and their
caregivers. Patients often experience care that is uncoordinated,
impersonal and unsupportive, which may leave them feeling incapable of
meeting the day-to-day needs of managing their chronic condition.
In Indiana, national, state, and local partners are working
together to implement a model of care for people with chronic
conditions. Indiana's five major objectives for its chronic disease
management program are as follows:
Provide consistently high quality care to Medicaid recipients that
improves health status, enhances quality of life and teaches
self-management skills.
Provide support to primary care providers and integrate primary care
with case management.
Utilize and strengthen the public health infrastructure.
Reduce the overall cost of providing health care to Medicaid patients
suffering from chronic diseases.
Achieve long term results by changing the way primary care is
delivered across the state, not just for Medicaid.
The key themes underlying the objectives are: patient self
management, involvement of primary care providers, utilization of
public health infrastructure and cost effectiveness. Most importantly,
Indiana's program eventually aims to change the way care is delivered
statewide--regardless of payer source and regardless of illness.
We are initially targeting recipients with diabetes and congestive
heart failure (CHF) and are quickly expanding to include asthma,
stroke, hypertension and HIV/AIDS. Other chronic diseases will be added
as appropriate and necessary. The clinical priorities of each condition
are based on currently available scientific evidence. The principles
used to improve care for the chronic conditions include:
Implementation of the Chronic Care Model in the primary care
settings.
Creation of a care management network to provide support to primary
care practices.
This will begin through a series of ``Collaborative'' learning
sessions, which will serve as the foundation for spreading the Chronic
Care Model statewide. The Breakthrough Series Collaboratives were
developed by the Institute for Healthcare Improvement (IHI) in the mid
90's to facilitate health system change. Participants in the
Collaborative will learn and implement an organizational approach to
caring for people with chronic disease that utilizes and supports a
comprehensive, sustainable locally based care network. The
Collaborative model will be implemented statewide in a phased approach
over a twelve-month period by sharing the best available scientific
knowledge on the care for people with these conditions, and by learning
and applying methods for change in the delivery of primary care.
STATE OPTIONS FOR MANAGING CHRONIC DISEASE
In the 2001 legislative session, the Indiana General Assembly
mandated that the Office of Medicaid Policy and Planning (OMPP)
contract with a commercial vendor to provide disease management to
recipients with diabetes, congestive heart failure, asthma, HIV/AIDs
and to provide case management for recipients with the top 10% of
costs. OMPP issued a request for proposal (RFP), received bids from
four vendors, selected one and began negotiations. Eleven months later,
OMPP canceled the procurement. In the 2002 legislative session, the
General Assembly removed the requirement that OMPP contract with a
commercial vendor.
We learned that there are options other than the commercial vendor
approach, and it is important for other states to know that alternative
options exist. Many people assume there are just two choices: ``make''
or ``buy''. ``Make'' usually implies starting from scratch and states
are legitimately concerned about the time, resources and potential
duplication of effort of that approach. The ``buy'' option is
attractive because states can hold a vendor accountable and augment
scarce state resources. The question is what is the state left with
when the contract ends. Luckily, there is a third option: ``assemble''.
The assemble approach is basically a hybrid of the make or buy models
that allows states to assemble the best pieces together into a locally
based infrastructure that supports and enhances the existing state
public health infrastructure. Indiana chose the assemble approach, but
it is important to note the pros and cons of each option.
There are two major options in the ``Buy Model'': outsourcing
completely to a commercial vendor or utilizing commercial chronic
illness software. Based on our analysis, we identified some of the
major pros and cons of each to be as follows.
Buy: Commercial Vendor Approach
------------------------------------------------------------------------
Pros Cons
------------------------------------------------------------------------
One stop shopping......................... Little or no local input or
involvement of providers or
community
Access to resources (products and people). Jobs & revenue associated
with running the program go
out of state
Financial risk accepted by vendor......... Risk negotiation difficult
for Medicaid populations
No sustainable investment in
infrastructure
------------------------------------------------------------------------
Buy: Chronic Illness Software
------------------------------------------------------------------------
Pros Cons
------------------------------------------------------------------------
Off the shelf program, already developed.. No local physician or
delivery system input or
involvement
Limited/no flexibility with
survey tool
Telephonic case management
only
System does not always
interact with claims
systems, makes reporting
duplicative
------------------------------------------------------------------------
Assemble: Chronic Care Model
------------------------------------------------------------------------
Pros Cons
------------------------------------------------------------------------
Evidence based interventions with proven Requires significant state
results. resources
Allows for local input and experience in State retains financial risk
developing program components.
Promotes patient self management.......... In the short term, may take
longer to develop and
implement (note: this was
not the case in Indiana)
Carries over to improve care for all
patients in a practice
Keeps revenues and jobs in state
Provides on site as well as telephonic
case management
Creates a comprehensive, sustainable
locally based infrastructure with
effective case management in place to
support primary care providers and
Medicaid members.
------------------------------------------------------------------------
INDIANA'S CHOICE: CHRONIC DISEASE MANAGEMENT PROGRAM (ICDMP)
During the period of negotiations with the commercial vendor,
Indiana was chosen to participate in a Policy Academy on Chronic
Disease Management and Prevention sponsored by the National Governors
Association. A team of state policymakers, legislators and community
stakeholders attended a planning session and developed a strategic
action plan. As part of that process, we became introduced to experts
in the field of chronic disease management and began to question if
what we had asked for in the RFP and were in the process of negotiating
was in the long-term best interests of the State. As we learned more
and the negotiations narrowed to debates over guaranteed cost savings
as opposed to interventions, protocols and quality improvement, we
concluded that the commercial vendor approach we had originally
envisioned was no longer the model we wanted to pursue. We enlisted the
support of Dr. Ed Wagner, Director of the MacColl Institute for
Healthcare Innovation, Center for Health Studies, Group Health
Cooperative, and his team in developing a program grounded in the
principles of the Chronic Care Model. The Chronic Care Model was
developed through Improving Chronic Illness Care (ICIC), a national
program supported by the Robert Wood Johnson Foundation. The Chronic
Care Model focuses on improving care delivery and promoting system
change through the use of evidence based care practices, strong patient
self-management and extensive involvement of primary care providers and
practices. The Chronic Care Model reinforces all the elements necessary
for creating a sustainable, comprehensive, locally based
infrastructure:
Evidence based guidelines
Tools to support and assist providers
Strong patient self management and involvement in health care
decisions
Investment in public health infrastructure
Creation of sustainable infrastructure in a locally based manner that
benefits state as a whole and leaves the state better off than
when it started
Long term focus on improving quality vs. short term focus on
``guaranteed'' savings
The Chronic Care Model changes the approach of medical care from
reactive, acute care for illness to a preventive, coordinated care
model for health that will decrease complications and eventually reduce
costs. As mentioned earlier, we will be spreading the Chronic Care
Model through a series of Collaborative learning sessions developed by
the Institute for Healthcare Improvement (IHI). IHI has been a valuable
partner in teaching us how to test change concepts and develop and
implement quality improvement initiatives in the medical care
environment.
ASSEMBLING THE INFRASTRUCTURE
Using the assemble approach, the first step is to identify the best
components and partners available to build and strengthen the existing
public health infrastructure and that will facilitate the interaction
between primary care and chronic disease case management statewide.
The ICDMP has the following major components and partners:
Program Management. Medicaid and the Department of Health are jointly
responsible for the program including policy development,
contracting and monitoring performance.
Primary Care. The focal point of patient care is the primary care
physician. Key elements of the ICDMP are designed to provide
information and resources to support the physician. The
Medicaid provider community is our partner in this component,
and we are working with them to ensure our reimbursement is
aligned with the outcomes we hope to achieve.
Care Management. Care management is comprised of:
A Call Center that monitors patient status and follow-up based on
the established protocols. We partnered with the existing
Medicaid call center vendor to provide these services to
take advantage of the relationships, credibility and
knowledge they already have with our recipients and
providers. The call center services are available for all
ICDMP patients.
A Nurse Care Manager network whose nurses provide more intense
follow up and support to a smaller group of high-risk
patients. We partnered with the Indiana Minority Health
Coalition and the Indiana Primary Health Care Association
to hire nurses and deploy them statewide, according to
physician practice and geographic area. These organizations
are natural partners in that they have established
relationships and credibility across the state and are
fairly evenly split between urban and rural areas, which
prevent overlap or duplication.
Patient Data Registry. An electronic data registry is available to
physicians and can be used for all patients. For Medicaid
patients, it will be populated with claims data and case
management data. We partnered with Mountain Pacific Quality
Health Foundation, the Medicare Quality Improvement
Organization for Montana, in the development of the Chronic
Disease Management System (CDMS). CDMS contains the ICDMP care
protocols and clinical guidelines, patient education materials,
Medicaid claims data, reminder and recall functions and other
clinical data entered by the call center, providers or nurse
care managers.
Measurement & Evaluation. Measures of program performance are being
established using both claims history data and individual
health outcomes indicators for both an intervention and control
group. We partnered with the Regenstrief Institute, of the
Indiana University School of Medicine, to perform a statewide
evaluation as well as a randomized controlled clinical study
within Marion County (Central Indiana region). We are committed
to a rigorous evaluation of this program that will measure
total costs (not just savings from reduced hospitalizations)
and identify which components are effective as well as those
that are not achieving the intended outcome and need to be
changed. For an evaluation to be meaningful, it must be clearly
structured to measure total program effectiveness. As such,
when evaluating chronic disease management programs, it is
critical to examine all costs for all patients during the
intervention. Looking only at selected costs or only at the
most expensive groups of patients can be deceiving.
In closing, I'd like to thank the Members of the Subcommittee for
the opportunity to discuss this important issue with you. The Indiana
Chronic Disease Management Program was assembled with the help of many
experts in this field to solve a public health problem that reaches far
beyond the Medicaid program alone. We would be more than happy to share
any of our materials (clinical protocols, consensus guidelines, patient
education materials, call center scripts, patient identification
criteria, etc) with any state that is interested in assembling their
own chronic disease management program. Thank you again for your time,
and I would be happy to answer any questions you may have.
Mr. Bilirakis. Thank you, Ms. Bella, and I would ask all of
you to feel free--we would welcome any additional information
you might have to furnish to us, such as the information that
you have talked about becomes a part of the record. So please
basically help us to come up with whatever changes need to be
made and any need to be made, improvement and that sort of
thing.
Well, Dr. Medows, I guess it is no surprise that I am going
to start with you. I am just pleased that you and others spoke
with great emphasis on benefits to the patient, the patient,
slash, beneficiaries, slash, patient. You know, when you talk
about savings, and they are very significant obviously, because
there is only so much there, and we want to be sure that the
dollars are best used and in the best way possible. But I think
the bottom line is the benefit to the patient. And so you have
talked about improving quality of care, improve health
outcomes, et cetera. I want you to feel free to submit to us in
more detail, if you can, some of your experiences in that
regard, you know, and what you have learned.
You talked about the four areas that Florida has learned. I
find that very significant. And so if you can go into details
there and in writing to us, and also, the Promotora program,
because, again, as your written statement indicates, a lot of
the chronic diseases have disproportionate impact on many
minority populations, and apparently a Promotora program is
being very helpful in that regard in conjunction with working
with Bristol-Myers. So please expand upon that, give us more
details so we can learn more about it. And the reason is
because we can only go into so many things here orally, but it
could be very helpful.
The question that I would have is something that you
haven't mentioned regarding the Florida Legislature's Office of
Program Policy there, their study and their analysis, which
recently released a report that was very critical of the
funding, and I say very critical. Maybe very is wrong, but, in
any case, critical of the funding mechanism used to pay for
your disease management program. It indicated that the State
could have received more money through supplemental drug
manufacturer rebates rather than having the manufacturers pay
for a disease management program.
So the questions regarding that are do you believe that
Florida negotiated a fair deal in its negotiations from the
drug manufacturers? Does the analysis account for future year
savings that can be achieved through improved beneficiary
health as against if you have got the dollars and use them
toward that end; and what assumptions did the report make, if
you know, about all the manufacturers participating in the
value-added programs converting to supplemental rebate?
Now those are basically the questions. If you can take
maybe the rest of the time to respond to that, I would
appreciate it.
Ms. Medows. Okay. Thank you, Mr. Chairman.
I do believe that the negotiations were done fairly. In
2001, the Florida Healthy State contract was signed with
Pfizer, and at that time we believed that the rebate value with
us, with the State of Florida and Pfizer, would have been $33
million. Instead of that what we chose to do was take this in
terms of value-added funding for the disease management
program.
I would have to disagree with APAGA's conclusion that it
would be better to simply take that one-time savings and rebate
that would be non reoccurring as opposed to continuing the
program that was already serving over 100,000 individuals.
Mr. Bilirakis. Can you evaluate the dollars of the program
in terms of the Pfizer's--the drug manufacturers' part in it as
against the $33 million? Is that it, or are Florida
beneficiaries receiving more in terms of benefits?
Ms. Medows. I believe that they certainly are.
Mr. Bilirakis. Okay. Please continue.
Ms. Medows. I believe that because if we simply had done a
rebate, it would have been a nonreoccurring. We believe that
several assumptions were made that would not necessarily be
true: First, that if we took a rebate, that the money that
would be saved for that particular year would automatically be
sent back to the Medicaid program in terms of disease
management. We don't know that that necessarily would be true.
In fact, given budget crunch and budget shortfalls, I am not so
sure that it would have made it back to them, okay.
No. 2, this was an assumption that was made that the
pharmaceutical manufacturers would have agreed to a rebate if
value-added programs were not an option. The pharmaceutical
manufacturers do not have to do that. They do have a third and
fourth option. One is not to participate in our program at all.
And two is to have us to do a prior authorization-type program
which would be costly and a little bit prohibitive in terms of
resources and staff. They made an additional assumption, and
that assumption was not valuing what the benefits would be to
the individuals being served in that program and looking in the
long haul over the decreased health care expenditure because of
the improved health outcomes that we expect.
Mr. Bilirakis. My time is up. But, again, I would ask you
to expand as you may wish to your answer in that regard,
because that is certainly a significant point in our
deliberations.
And I now yield to Mr. Brown.
Mr. Brown. Thank you, Mr. Chairman.
I would like to start by asking unanimous consent to enter
into the record the Office of Program Policy analysis of the
Government Accountability Office of the Florida Legislature, if
I could, which discusses and illuminates some of Dr. Medows'
comments and contentions. If I could enter that.
Mr. Bilirakis. Without objection.
Mr. Brown. Ms. Bella, I would like to ask you and Mr. Simms
each a question. I first want to mention a comment my friend
from New Mexico Ms. Wilson made in her opening comments about
needing more data--and, yes, the hearing last week on Medicaid
showed we really don't get enough data. And I would ask the
committee at some point to help us get more information from
those--from those carriers, private, HMOs, both in Medicare and
Medicaid that don't collect data, frankly, as well as fee-for-
service, because they don't give us data on individual claims.
So I hope that we can work together and be able to get more
information and be able to understand both Medicare and
Medicaid better in the future.
Ms. Bella, you spoke generally of some of the reasons why
Indiana decided that the private vendor approach wouldn't lead
to the long-term sustainable and effective case management
model that you were seeking. Could you elaborate on how the
private disease management organization was interested in being
reimbursed, and can you approximate how much of the savings
earned by Indiana would have actually gone to them?
Ms. Bella. Sure. Thank you.
Briefly, they were--proposed to us a funding on a per-
member/per-month basis. At different points in the negotiation,
it was unclear whether you would be paying on eligible members,
enrolled members or engaged members. And so there was a lot of
variation there in terms of how you know if someone is truly
being touched and affected in order to generate a payment on a
monthly basis. They proposed to put a percentage of their fees
at risk, and that is one of the main problems that we had,
quite honestly, is that we spent a lot of time negotiating over
a guaranteed savings and not a lot of time discussing the
substance of the interventions. We ran into problems about how
to count savings for the Medicare dual-eligibles, for example,
and how to take into account the fluidity of the recipients as
they go on and off the Medicaid program.
Mr. Brown. Thank you.
Mr. Simms, it appears that because disease management is
new to a number of States, that monitoring and reporting and
benchmarks can be critical to creating future success,
obviously. What kinds of monitoring tools--if you would share
with us the monitoring tools, the reporting requirements that
North Carolina implemented through its--all its ACCESS I, II
and III program.
Mr. Simms. We have really made a lot of effort at getting
the process measures in place and looking at the chart audits,
those sorts of things, and that can be provided. Some of the
results of those chart audits can be provided to the
subcommittee.
Some other things that we have been looking at are some
practice profiles for the providers. We are looking at doing an
in-house sort of practice profiles that can be risk-adjusted to
give to the providers. We are learning that the feedback to the
docs are what really enables them to really begin looking and
working more aggressively to get things in place. But I can
give the subcommittee examples of those practice profiles as
well and what we are putting in place.
Over the last couple of years we have also done some things
with quality in relation to our patient population, looking at
the CAP survey, patient satisfaction, making sure that the
patients are feeling that the health care delivery system is
something that is meeting their needs as well.
Mr. Brown. Thank you.
And, Ms. Bella, one more question for you in the last
minute or so. Could you just describe to us how you--more about
the integration of the Department of Health, the physicians,
other providers, community resources and patients when you
develop the program that it seems to be more sustainable in the
long run? How critical is that integration to creating a more
effective and long-lasting program?
Ms. Bella. Thank you. That is a very important question,
Representative Brown. We convened a Chronic Disease Policy
Advisory Council that consisted of all the major insurers in
the State of Indiana, the medical associations and other health
plans as well as physician groups. They came to the table and
worked with us, so we got their buy-in and involvement early
on, which we believe helps engage them in the implementation of
our program.
In addition, we identified local resources across the State
who already have relationships with recipients and the provider
community as well as the public health infrastructure, and the
reason we believe that makes that more sustainable is because
they are invested in these decisions, and they are already part
of that health care system. And we are creating the
infrastructure with them, and we believe that that will make
them more active participants in that and vested in the success
and the long-term viability.
Mr. Brown. Thank you.
Mr. Bilirakis. Mrs. Wilson to inquire.
Mrs. Wilson. Thank you, Mr. Chairman.
I wanted to ask a question of Chris and also of the three
State representatives as well. In order to embark on these
programs, and in your case, Chris, with the States that you
work with, did the States require a waiver from CMS to try
this?
Ms. Selecky. Yes. In the case of Florida, we did have to
get a waiver, and it took about a year to go through that
process, which was unfortunate. It delayed the start of the
program. In New Mexico we are working with the managed care
organizations, so no waiver is required.
Mrs. Wilson. So the only waiver was the one that they had
to apply for to do managed care under Medicaid.
Ms. Selecky. Yes.
Mrs. Wilson. What about in the other States? Did you
require waivers, and how long did it take you? Dr. Medows, do
you want to----
Ms. Medows. It is actually variable in terms of the length.
There are some programs--we have had programs going on since
1997, so there are different people working in CMS at different
times, different emphasis on getting waivers through the
system.
And then you have to take into account that some of our
programs like the Pfizer Healthy State program was quite new
and complicated. I think we may have built some new laws just
around it, new rules. It took quite a bit of work.
Mrs. Wilson. Mr. Simms, did North Carolina require a waiver
in order to do what you wanted to?
Mr. Simms. Initially with our Primary Care Case Management
program, when we started in the early 1990's, yes, it was a
1915(b) freedom of choice waiver. But most recently, with the
BBA managed care regs, they allow you to do a lot of the
enrollment and linkage with primary care providers through the
State plan amendment process, and that is what we have been
able to do with the bulk of this population. It does not allow
you to mandatorily link the vulnerable or the special needs
population. You have to make sure that they recognize it is a
voluntary program for them. But for the bulk of the population
we were able to still mandatorily link them through the State
plan amendment process.
Mrs. Wilson. How about Indiana?
Ms. Bella. Indiana also has a 1915(b) waiver for our
managed care program, and we were able to add this. Basically
it is an amendment to that waiver to allow us to provide these
services.
Mrs. Wilson. With respect to Indiana, you mentioned that
there is a--I think you said Indiana University is doing a
study on measurement and evaluation. But aside from the kind of
studies where someone goes in and takes a snapshot look, what
kind of information systems do you have in place linking all of
these to know whether you are improving the health status of
the members?
Ms. Bella. We have what is on there referred to as the Web-
based patient registry, CDMS's chronic disease management
system, developed by the quality improvement organization for
Montana. And we have worked with them to--it is an electronic
patient registry that contains claims data, clinical data,
guidelines, reminder recall, anything that anybody that touches
that patient wants to put in there. So we use that.
In addition, we have softer measures that we obtained
through assessments that our call center is doing. We have
process measures that we look at; simply, is the person getting
their recommended eye exam. And then we have outcome measures,
mostly through the Regenstrief Institute.
And one point to note that IU is doing for us, they are
doing a statewide evaluation that will be a pre- and
postsnapshot look, as you refer to. But we do have a randomized
control trial going on as well that will provide an even more
rigorous evaluation, and our focus is on both process and
outcomes.
Mrs. Wilson. Chris, how does LifeMasters use information
systems to give you--what kinds of data systems do you have on
telling whether people are healthy or not?
Ms. Selecky. We have developed a very sophisticated data
base management system which brings in data from a variety of
sources, Medical Claims Administration demographic data, lab
information, pharmacy benefit information, and consolidates all
that information into an individual profile of every single
program participant with whom we work.
Mrs. Wilson. And then can you aggregate that data?
Ms. Selecky. Yes. So we have an individual profile, and
then we have an aggregated profile of the entire population. We
track over time improvements in clinical status and reductions
in utilization. And then we usually have that information pre
the program so that we know what the baseline is. We measure
what is going on during the program year, and then we do a pre-
postanalysis. We also do randomized control trials as well and
have third parties validate the outcomes.
Mrs. Wilson. One final question, if we can do it quickly,
and that is everyone--or several folks mentioned mobility on
and off of Medicaid eligibility. And I don't know whether you
know that off the top of your head what your mobility rates are
in Florida, North Carolina and Indiana, but if you do, what are
they? I mean, what percentage of your population is there at
the end of the year that you started with at the first of the
year or however you measure your mobility? Dr. Medows, do you
know, or should I just leave that one for the record?
Ms. Medows. I would rather actually get you something that
is much more definite. I can tell you that it is an issue of
people losing their eligibility coming back in, because that
disrupts care. And we try to make it so that if they--if we can
get them back on board within 90 days, that they are just
resuming instead of starting from scratch. But I can't tell you
an exact number right now.
Mrs. Wilson. Maybe if we could leave that question for the
record, and I would also ask to reserve the right to submit
additional statements for the record.
But getting at this issue of mobility is, I think, one of
the keys to addressing some of the problems we face with
Medicaid.
Thank you, Mr. Chairman.
Mr. Bilirakis. Thank you, Mrs. Wilson.
By the way, without objection, the opening statements of
all members of the subcommittee will be made a part of the
record.
Oh, Mr. Green is back.
Mr. Green. Thank you, Mr. Chairman.
Mr. Bilirakis. You are recognized.
Mr. Green. Thank you. I have a number of questions.
First, Ms. Selecky and Ms. Bella, in your testimony both of
you indicate that minority health is a component of disease
management programs, and as is representative, I have a 60
percent plus Hispanic district. I am especially interested in
the lessons you have learned on how to treat the population;
and as you point out, and we know in my own district, higher
incidence for diabetes and heart disease and certain cancers,
and in some cases less cancers with Hispanic women in one
particular area, and a host of other chronic illnesses.
Have you designed your programs, particularly in
California, but also in Indiana, to the unique needs of the
Hispanic community? I guess the overall minority community,
because some of these same indicators are in Hispanic
communities and African American communities.
Ms. Selecky. Yes, Congressman Green. We employ nurses who
speak Spanish so we can provide multilingual services over the
telephone and in person with our program participants. We
provide program materials in Spanish and Chinese actually,
because we have a very large Chinese population in the Bay
area. And we also adapt the content of our program to cultural
issues. There are definitely different issues around the way
that people interact with their physician, the way that their
families support them, the kinds of diet that they eat. And so
we have gone through, and, again, because we have got a
computer system that can adjust our program to each individual
that we work with and that guides our nurses through the
interaction with people, we very definitely customize the
program to language and cultural and other kinds of issues.
Mr. Green. Ms. Bella.
Ms. Bella. Our materials are also available in Spanish, and
our nurse care managers in our call centers employ bilingual
workers as well.
I would say the way we have been most successful in that is
partnering with our Minority Health Coalition, who represents--
who has Hispanic affiliates across the State, and they have
helped us tailor those interventions to understand that the
involvement of the community or involvement of the family may
be different given the different cultural need. And so through
our partnership with them we have been successful at tailoring
our interventions in a way that we couldn't have done. We
wouldn't have had that knowledge base on our own. So, yes.
Mr. Green. Ms. Bella, I will ask you if this committee
enacted the Healthy Communities Access Program modeled after
the successful CAP, the administration project and CAP provides
grants to help agencies coordinate preventative and primary
care for 44 million Americans without insurance. And I know
that Indiana has received several CAP grants, one in Marion
County, central Indiana and South Bend. And I think the
objective of the CAP program, to improve coordination of health
care for uninsured Americans, is similar to the Indiana Chronic
Disease Management Program.
Can you tell me whether your program works with the CAP
Program or the--is there cross-pollination, I guess, between
the two?
Ms. Bella. There is. That has given us a unique
opportunity. With the most recent funding that we received, we
were doing a survey and health assessment of the uninsured in
Indiana, and we included specific questions related to chronic
illness to try to understand the prevalence across the State,
again, knowing that we see a lot of overlap between the
uninsured and Medicaid and other payer sources. And so our goal
is to include and develop a system that covers everyone.
So it is very closely integrated with the efforts through
our CAP grant and looking at how to address chronic needs
across the State of Indiana. We appreciate those funds.
Mr. Green. Thank you.
Mr. Simms, according to your testimony, North Carolina
Primary Care Case Management Program creates a physician
provider network that includes nurse care managers to implement
the disease management program, which is similar to the diagram
here in Indiana. Can you explain the motives for physicians and
providers to join together in implementing that disease
management program?
Mr. Simms. Yes. They are very committed to having control
and the opportunity to direct the local health care delivery
system for the patient population there in their local
communities, so they see this as the opportunity to continue
and to buildupon that. The providers in North Carolina have
been very committed to serving Medicaid populations, especially
the pediatric providers, and so they have really worked very
closely with the Medicaid program with the implementation of
this and see this as their opportunity to really help get the
health care delivery system at a local level in place that they
can continue to maintain the level of quality of care that they
have been providing.
The other thing is that they also see it as the opportunity
to be able to show our legislature that we can implement a
local infrastructure that can contain costs, improve quality,
and therefore prevent them from having to have their rates
reduced as well.
Mr. Green. Okay. Thank you, Mr. Chairman.
I know I have a little time left. It is interesting last
Friday morning in Houston, I actually met with the chief of
neurosurgery at the University of Texas Health Science Center
in Houston, and one of his concerns is the lack of--he sees
what happens because they have a trauma care unit at Memorial
Herman Hospital, but the concern about utilizing case
management and nurses more into the process, and the program he
talked around about was similar to what we are hearing about
today.
Thank you, Mr. Chairman.
Mr. Bilirakis. I thank the gentleman.
Without objection, there is a statement by Sandata
Technologies that they wanted to submit to the record, and
without objection, that will be made part of the record.
[The information referred to follows:]
Prepared Statement of Sandata Technologies, Inc.
Chairman Bilirakis, Ranking Member Brown and members of the
Subcommittee: We appreciate the opportunity to offer this statement on
behalf of Sandata Technologies, Inc. in connection with the
Subcommittee's consideration of Medicaid reform and today's hearing on
``Evaluating Coordination of Care in Medicaid: Improving Quality and
Clinical Outcomes.''
As you know, the Medicaid-funded health care system is under great
pressure to deliver quality health care to eligible beneficiaries while
controlling Medicaid expenditures. Policy-makers have begun to rethink
ways to deliver quality health care services in the most cost efficient
manner possible while preventing the loss of limited health care
dollars due to waste, fraud and abuse. We commend the Subcommittee's
efforts to advance a thoughtful discussion of these important policy
objectives.
Today's hearing appropriately focuses on the quality of patient
care within the Medicaid system. To improve patient outcomes, we
believe it is critical to ensure that the individual patient's plan of
care is followed. It is important, therefore, for providers to be able
to leverage easy-to-use, proven technology to accomplish that
objective.
More and more of our Medicaid-funded health care will be delivered
in home- and community-based settings. To meet the growing needs of
patients, home care providers can rely on cost efficient, proven
technology to deliver efficient, appropriate, high quality home health
care throughout the United States. This technology--known as
``telephony for home care''--enables providers to deploy a capable
management and information technology infrastructure to prevent fraud
and abuse and ensure monies are not squandered as necessary services
are delivered to achieve positive health outcomes.
Telephony for home care delivers concrete benefits to State
Medicaid programs and to Medicaid contracting home care providers, as
described below. Equally important, it helps ensure that eligible
Medicaid recipients receive the quality of care defined in their
individual plan of care for the appropriate cost.
Currently, the City of New York's Human Resources Administration as
well as the Nassau County Department of Social Services in New York
State, the Visiting Nurse Service of New York and select visiting nurse
associations in other jurisdictions mandate that their contracting and
sub-contracting home health care providers use telephony for home care
as a condition of contracting with Medicaid to deliver home health
services.
The use of telephony for home health care by Medicaid programs
delivers many benefits directly to State Medicaid home care programs,
for example:
It reduces Medicaid expenditures without cutting benefits to Medicaid
beneficiaries.
It ensures payment is limited to the actual hours of service
performed by providers for the Medicaid home care program
instead of what might be written on a paper timesheet (e.g.,
the City of New York Human Resource Administration's Medicaid-
funded home care program saves 5.5% of expenditures from the
difference between authorized hours and actual hours of service
provided),
It verifies patient coverage and provides payment only for visits
that actually occur in the patient's home or other approved
location.
It improves the quality of care delivered by tracking tasks
accomplished and matching them against the patient's plan of
care.
It reduces the time and costs of audits by providing a permanent,
comprehensive audit trail via telephony.
It provides important aggregate oversight data at the county, state
and national level.
Equally important, telephony delivers important concrete benefits
to Medicaid contracting home care agencies, for example:
It cuts administrative costs by collecting all home care visit data
from the patient's home electronically, eliminating manual data
entry of time and attendance, tasks accomplished, etc., for
billing and for payroll.
It ensures the delivery of quality care in accordance with the
patient's plan of care--eliminating missed visits and verifying
that ``the right worker was at the right place, at the right
time, performing the right tasks.''
It improves management visibility over field operations--i.e.,
telephony collects visit data in real time from the patient's
home, making it available to the supervisor in real time, so
they know exactly what is going on in the field.
There are no upfront hardware or software costs, enabling providers
to ``pay as they go.''
Likewise, providers benefit from the permanent, comprehensive audit
trail.
A recent review of Medicaid home and community-based waivers by the
U.S. General Accounting Office (GAO) concluded that the Centers for
Medicare and Medicaid Services (CMS) does not adequately monitor state
Medicaid and Medicaid waiver programs and the quality of beneficiary
care.1 According to GAO, the most common problems included
``failure to provide necessary services, weaknesses in plans of care,
and inadequate case management.'' 2
---------------------------------------------------------------------------
\1\ Long-Term Care: Federal Oversight of Growing Medicaid Home and
Community-Based Waivers Should Be Strengthened, GAO-03-576 (June 20,
2003).
\2\ Id.
---------------------------------------------------------------------------
Telephony, with its accurate real time data collection capability
and management data presentation, can play a significant role in
addressing these concerns by enabling improved ``visibility'' into
field operations and improved government oversight. In addition, this
service is available wherever telephone service is available, even
under crisis conditions. During the recent blackout, for example, the
service continued to collect data, so Medicaid programs and home care
providers had assurance and confirmation that patients were being
served.
In closing, the use of telephony for home care can provide concrete
benefits to State Medicaid programs, to home health care and other
social service providers, and to eligible Medicaid beneficiaries. We
look forward to working in partnership with you as the Subcommittee
considers ways to strengthen the Medicaid program and to ensure the
continued viability of this important safety net for our nation's most
vulnerable patients.
Thank you for your consideration of our views.
Mr. Bilirakis. I wanted to do something different just for
the next few minutes.
The bottom line is quality of care, and we all agree, some
States have chosen to do it themselves without the private/
public, if you will, and other States have chosen to go the
other way for whatever reasons. I wonder, could we take a few
minutes, and I will control the time, where you all might feel
free to ask each other questions? I mean, Dr. Medows, are you
not curious as to how well Indiana is doing their way, and Mr.
Simms, and vice versa and that? Well, if you are, raise
questions.
Mr. Hilferty.
Mr. Hilferty. Mr. Chairman, I am sorry, if I may, from our
vantage point we truly believe there are situations where
States, much like this Indiana program, can do it on their own.
What we have come to realize is there are opportunities where
States and private entities can partner and collaboratively
work to get the data that is needed to do the health outcomes
analysis, to really work in partnership to improve quality,
improve access and, most importantly, reduce cost. So from the
private perspective we are not saying it should be all private,
but we are saying that there are situations.
Mr. Bilirakis. So you are impressed with the way Indiana is
doing it, but you say that there is a possibility that there
could be some improvement in there.
Mr. Hilferty. Well, I think time will tell. I mean, we were
one of the bidders on the--with LifeMasters on the business in
Indiana. Time will tell, and I think the importance of
collecting the data, analyzing the data and seeing if the
outcomes are there--we will see if it works.
Mr. Bilirakis. Go ahead, please.
Mr. Brown. Ms. Bella, if they had won--if Mr. Hilferty and
Ms. Selecky had won the bid, how would it have been different
in Indiana from what happened, from what you have been able to
do?
Ms. Bella. In my opinion, we would have had much less
involvement in the development of the interventions. We would
not be involving the community as much. The focus that we found
for that approach was more on the patient management, the
particular patient as opposed to managing and developing a
system and an infrastructure. And so we are really stepping
back and putting together a system for the State as opposed to
focusing on a recipient with congestive heart failure because
we want long-term system change. And so I think that that would
have been the biggest difference.
Mr. Bilirakis. Any response, Mr. Hilferty?
Mr. Hilferty. Well, I think that is accurate, an accurate
portrayal. I think that the importance that we bring and the
data bases, whether it be LifeMasters or AmeriHealth Mercy
bring to the table, is we are able to analyze by disease state
and to categorize folks. Yes, there is the importance of the
community contact, but categorize folks by a disease state and
develop programs to truly monitor their health status and
improve that status.
Mr. Bilirakis. Dr. Medows.
Ms. Medows. Yes, sir. I think I have kind of the best of
both worlds because I actually have contracts with a private
entity who is providing us with the funding, and providing us
with some software, and providing us with some of their
expertise, but at the same time, make no bones about it, the
patient is still being cared for by their primary care
physician. They are in their communities with their community
hospital, with their community clinics. It is not a new third
party just coming in and providing care. They are being treated
in their home with people that they know. And then they are
getting, on top of that, extra attention, extra support, and
they are getting things that they weren't able to get before.
It is not just a matter of a nurse calling and finding out if
you have gone to the doctor.
But, like you say, we have put that personal touch. It is,
why didn't you make it? Was it a transportation issue? Was
there an issue with you paying your copay for your
pharmaceutical? Was it that you didn't understand what you were
supposed to do?
So I don't know that we would have to go all State or all
private. I think, you know, I feel much more comfortable with
the way that we have it compiled, that it is a combination of
both. But again, as long as the focus is on improving the
actual care that is being delivered to the patient and their
improved health outcome, I think any of the options would be
fine as long as that is the focus.
Ms. Selecky. Mr. Chairman, might I weigh in on this?
Mr. Bilirakis. Sure.
Ms. Selecky. Because I--you know, I commend all of the
States for all of their efforts. And disease management is a
relatively new phenomenon. It is a very difficult thing to do
well. There are a lot of moving parts, and health care is about
delivering quality care from physicians to their patients. And,
in my opinion, disease management is really a platform to
deliver evidence-based medicine and enable physicians to
deliver better care to their patients. And we provide the
technology and communication platform and some of the support
services that help offload physicians who are very busy and who
don't have time to provide educational and coaching services to
their patients.
We believe very strongly in supporting the doctor/patient
relationship. When we work in a community, we work equally with
the doctors and the patients. We send the physicians exception
reports about how their patients are doing in between office
visits. We send them relevant information about how they might
deliver better care to their patients. And I think that there
is definitely room for very close collaboration between public
entities and private entities. We do it with our commercial
employer and health plan customers all the time. We wrap our
programs into their existing efforts, and I believe that there
is room for all of the different, you know, very dedicated
players in this.
Ms. Bella. If I could add one thing. I want to echo what
Dr. Medows said. I am afraid that sometimes States feel like
there are just two choices. It is make or buy. And as I
indicated in the testimony, we have chosen what we call the
assemble approach. We are still buying some of our services,
but the difference is we are in control of designing the
program, and it is a system focus.
So if I think--again, if I had to answer your question
again about what is different, it is that at the end of the day
in the program we have put together, the resources remain in
the public health infrastructure in the State of Indiana
because we have made an investment there. And what we were
concerned with with another program with a little different
focus is that the resources leave the State, and we don't
retain that expertise or that knowledge base or that critical
infrastructure.
But it is not--you know, the two are not mutually
exclusive. You can have a hybrid, but I think it is very
important for States to understand that they with their public
health system can do this themselves. And as--what is not to be
minimized is the technical assistance, and best practices that
were shared with us by the McCall Institute, the Institute for
Healthcare Improvement, and improving chronic illness care are
available to all States, and that is really the meat of what
you need. What is on this little CD is the key to intervening
with your providers and your patients, and those things are
available in the public domain, and that helps us all maximize
our investment. And so----
Mr. Brown. If I could pursue that, Mr. Chairman, for a
moment.
Mr. Bilirakis. By all means.
Mr. Brown. Ms. Bella and then Mr. Hilferty, you talk about
the public resources thing and the public domain, and I guess
that is dollars and health care resources. In terms of
information, we talked about that earlier a little bit. You--I
assume that you have information how much each patient costs,
how much goes to overhead, all of that. Do we get that, Mr.
Hilferty, from you? Can we get that for what every patient
costs?
Mr. Hilferty. Yes.
Mr. Brown. That is made available to Medicaid.
Mr. Hilferty. Yes. Yes, it is, Congressman Brown. If you
take Pennsylvania, for example, Pennsylvania has implemented a
risk adjustment rating program where the way the plans are, it
is analyzed what rate you will get in the coming year is
partially done by your case mix and the data you provide to the
State. And it is done through practice profiling and encounter
data, and it is incumbent upon the private plan to supply that
data, and then the State goes through the calculations to
figure out the risk adjuster and provide the rates for the
private plan.
Any--the key point is that any Medicaid managed care
program that works, that includes the private sector, has to be
done collaboratively. It can't be all one or all the other, all
private, all public. But it is incumbent upon the private
entity to provide the data, but not only to provide it, but to
verify the data so that the States know that the outcomes are
there, and that they can come up with a pricing strategy for
those services.
Mr. Brown. And the data coming from you, from others in the
private sector, from the private contractors is every bit as
comprehensive and detailed as the information that Ms. Bella
would get from her public program.
Mr. Hilferty. The difference there is that our data is--we
can't confirm that it is--or our issue is related to being able
to access the local provider and get them to fill out encounter
data on time. An issue that we struggle with, quite frankly, is
the timeliness of getting that data.
Ms. Bella, when she goes through a program, there is that
individual claims data that you referenced earlier that is
there on a retroactive basis. But as we have gotten better at
getting the data from our private physicians, from our private
hospitals, yes, we are providing the same timely information.
And I would be more than happy to provide that to the committee
from the States in which we do business.
Mr. Bilirakis. Would you do that, please.
Mrs. Wilson. Mr. Chairman.
Mr. Bilirakis. Mrs. Wilson.
Mrs. Wilson. If I could follow up on this a little. The
data, claims data, is one thing, but that is about what we paid
out. And I think one of the problems with Medicaid is that it
is set up to pay claims. Does Indiana--has Indiana invested, or
North Carolina or Florida invested, in the information systems
to give you any information about the health status of--you
know, can you tell me the improvement in A1-C for diabetics
dependent on Medicare--I am sorry, Medicaid; or reduction in
asthma admissions in emergency rooms?
Ms. Bella. We have our patient registry set up to collect
that information now. It is dependent on the provider practices
entering that information. And so our job then----
Mrs. Wilson. So we have the same problem that Dan has.
Ms. Bella. Well, except that we provide a migration from
their system to dump into our system and make it very easy on
them. If we need to send someone in there to do chart pulls and
medical reviews to get us that data, we will do that because it
is that critical. In addition, we can also get the data entered
by the care managers or the call center, so it can come from a
variety of sources, and we just work to figure out how to best
get that.
But you are right. I mean, you need lab values. You need
the richer clinical data to support the administrative data.
But a large successful component of ours is also the pharmacy
data. That can tell you an awful lot. In our system--I mean, in
everybody's Medicaid system, that is real time-instantaneous
data. And so much of the compliance is driven by their
pharmacy, that you can use that again because it is real time
as opposed to your standard medical claims to really provide
you with that indicator you need to get in and manage that care
quickly.
Mr. Hilferty. I think the point you make, Congresswoman,
around asthma is a good one. If you look at west Philadelphia,
for example, juvenile asthma is growing at alarming rates, as
it is nationwide. Well, what we are able to do is by engaging
the member, the member's parents in education and from
everything to what meds they should be taking to ways to
relieve stress to work when there is an emergent situation,
what we have found is that we are able to take the data from
their well visits, their physicians, their emergency room
encounters and also the use of pharmaceuticals and really
receive the improvement and the care to this membership. And
that is something that disease management and case management
provides that frankly is proactive in really analyzing if care
is improved and if health status is improved.
Mrs. Wilson. Mr. Simms.
Mr. Simms. Yes. I think one of the things, and I agree with
Ms. Bella, that we are having to look at ways to do the process
measure, for example, the chart audit, of really getting folks
in to be able to provide feedback to the docs immediately,
showing them, okay, this is what you are doing with your
process measures and specific to asthma.
Some other things that we are looking at doing in North
Carolina is working with the school systems as well to begin
looking at has there been a reduction in number of days missed
by the children, by the Medicaid children, and comparing it to
ways that we should see improvement in that area because of the
asthma disease management initiatives. So--and then combining
that with the data that we are able to pull from the claims
data that will give us the ability to provide the practice
profiles back to the doctors and let them know what is
happening.
But, again, that is a challenge that the Medicaid programs
face in that if you are really building it only upon claims
data, then you have got a great challenge there. But we as well
have a Web-based management system where the care managers have
to enter the data in there. And so we are encouraging and
continuing to stay on the care manager and the networks to make
sure that information gets entered as timely as possible.
Ms. Medows. I would just say ditto, but we do the same
thing. I mean, just using claims data like you said just gives
you the financial picture, and what we are looking at is the
actual patient picture: Are we improving the quality of care;
are we improving the quality of their health. And what we do is
pretty much the same. We get that information from the patient
themselves, we get it from their physician, from the care
manager, who reaches them through the call center nurses and
health care professionals that they reach that way as well and
take a look at that, and look at markers that we know are
associated as benchmarks for each disease state. Is it
hemoglobin A1-C for diabetes?
But there is also did they get their eye exam this year?
Did they have their retina examination for diabetic
retinopathy? Did the asthmatic people--did they report that
they are actually using those peak flow meters that we gave
them? People with CHF, are they actually weighing themselves?
Are they telling us the truth when they give us their weight?
Are they actually taking the medication, and if not, why? And
do they notice themselves an improvement in their health and in
their well-being?
And I think it is important to ask them to give us that
input as well, and we take that all into account. That is
actually, I think, a truer measure of our success.
Mr. Bilirakis. Wonderful.
Well, there will be, as per usual, a series of questions
which will be presented to you, and we would appreciate a
timely response to them.
I would also ask maybe can you also furnish us a typical
case, you know, the step-by-step process of how you handle a
typical case in every one of your areas? I think that would
be--could be very helpful.
And your just being here is so very, very helpful. I think
we have had a good hearing. Not many members here, but, you
know, we have no votes until after 6:30, and that happens on a
day like that where many members are not here yet. But there is
great interest in the Medicaid program on this committee. Thank
you so very much for your help.
The hearing is adjourned.
[Whereupon, at 11:40 a.m., the subcommittee was adjourned.]
[Additional material submitted for the record follows:]
Prepared Statement of American Dental Association
The American Dental Association (ADA) is pleased to submit
testimony for the record as the committee examines the challenges
facing the Medicaid program and how to evaluate coordination of care
within the program.
On behalf of the dental profession, the ADA wants to make clear
that dentists find it unacceptable that in 21st century America there
are children who are eligible for public assistance who cannot sleep or
eat properly and cannot pay attention in school because they're
suffering from untreated dental disease--a disease that can be easily
prevented. As a nation, we must recognize how critical oral health is
to overall health--especially to the healthy development of a child--
and find the political will to do a better job of caring for the next
generation of children. The dental community is committed to working
with Congress, the federal agencies and the states to address and
remedy this fixable problem.
The oral health community has come a long way these last few years
in working to address issues affecting access to oral health care.
Dental providers have joined with governors, state legislators,
Medicaid officials and many others to tackle barriers impeding
children's access to care present in the Medicaid program. In response,
some states have worked to make oral health a priority, but as a result
of serious state budget cutbacks, many more have lost ground.
In the absence of effective public health financing programs, many
state dental societies have sponsored voluntary programs to deliver
free or discount oral health care to underserved children. Private
dentists and community organizations are working to do what is
necessary to reach out to these children; however, charity alone is not
a permanent system. Congress and the states must work with dentists to
establish an improved health care system for the delivery of oral
health care under Medicaid to our most needy and vulnerable citizens.
Because of devastating budget deficits, states have been forced to
make difficult spending decisions, and dentistry has taken a serious
hit. States are eliminating or severely reducing optional dental
benefits under the Medicaid program for adults. These are adults who
will not be able to gain employment in public focused jobs due to the
affect poor oral health has on appearance, or be able to function
properly due to chronic oral pain. Not having access to needed oral
health care, many will end up in an emergency room. The resulting cost
of emergency room treatment for patients and taxpayers far exceeds the
cost of preventive dental care. In addition, emergency room care is
only limited to pain management, so these individuals will still go
without necessary treatment to end their suffering.
THE CURRENT SITUATION
Oral health care for the nation's poor is a patchwork of
chronically underfunded, poorly administered programs. Many state
Medicaid programs shortchange dental care, providing payments that fall
far short of the cost needed to deliver care. This results in an
insufficient number of dentists who can participate in the program. The
result--underserved children and families often do not have access to
necessary oral health care.
A recent ADA analysis of dental Medicaid programs across the
country shows that only one in four children eligible for Medicaid
receives access to needed dental services. This is true despite the
fact that federal law requires states to cover dental services for
Medicaid-eligible children through the Early, Preventive, Screening,
Diagnostic, and Treatment program (EPSDT). It is critical for
policymakers at the federal and state level to acknowledge that oral
health is integral to general health and well-being and that we work
together to improve the Medicaid program to increase the participation
of providers, improve the delivery of services and enhance access to
care for those most in need.
As an optional benefit under Medicaid, adult dental care is often a
poor stepsister to medical care, facing restrictions or elimination
during tough economic times and often not reinstated when times
improve. Some states simply do not cover dental care for adult Medicaid
beneficiaries, and many others are cutting back. The result--
underserved and vulnerable adult populations, including the frail
elderly do not have access to necessary oral health care, which can be
even be life threatening since we now know that oral disease is
associated with systemic diseases such as diabetes and heart disease.
With the current state budget deficits, dental benefits have been
severely reduced across the country both within Medicaid and the State
Children's Health Insurance Programs (SCHIP):
Georgia recently passed a state budget proposal to eliminate dental
coverage for SCHIP children (an optional benefit) and also
eliminate adult dental benefits.
Michigan eliminated adult dental coverage earlier this year,
eliminating care for over 600,000 adults.
Texas eliminated dental SCHIP coverage earlier this year.
Facing tough budget decisions, many other states have frozen
enrollment or reduce eligibility in their SCHIP or Medicaid programs.
Others are considering how to seek federal assistance to reduce federal
mandates to provide access to dental services through the EPSDT
program. All of this devastates access to needed oral health care for
our country's most vulnerable.
NEEDED FEDERAL SUPPORT AND RESPONSE--EXAMINE STATE MODELS
Dentists seek to work with members of Congress, the Centers for
Medicare and Medicaid Services (CMS) and states to improve the Medicaid
program in terms of financing and administration in order to increase
dentist participation. Several problems affecting provider
participation have been identified--these problems include Medicaid
reimbursement rates at less than what it costs dentists to provide
care, concern with the dental administrative structure, excessive
paperwork and other billing and administrative complexities, and lack
of case management and other social barriers that result in a high rate
of broken appointments.
There are several ways to address these recognized problems. One of
the most critical strategies is for states to be able to raise Medicaid
rates to more closely mirror the marketplace, rather than allow
dentists to be reimbursed for care at significantly less than what it
costs them to provide it. Without federal support, this may not be
possible, given the economic situation. In some states, inadequate fee
increases set a standard in the state--sometimes for as many as 15 or
20 years. In many states it is not uncommon to find that Medicaid
reimbursement rates for dental care have not been adjusted since the
1980's--not even for cost-of-living adjustments. How can dentists
effectively provide care to patients if the system will not afford that
care?
Recent state budget cutbacks have escalated the problem of
inadequate reimbursement rates. Dentists who have signed up to
participate in the program are often punished as their legislature
targets provider reimbursement rates as a means to reduce state
Medicaid expenditures. In 2000, for example, the Iowa legislature
increased reimbursement rates from 60 to 70 percent of a dentist's
usual charges--only to cut these rates to half that amount in 2002. It
is impossible to achieve increased and consistent dental participation
in such an inconsistent system.
The good news is that there are success stories. The bad news is
that state budget deficits threaten these success stories. A recent
study conducted by the ADA, State Innovations to Improve Access to Oral
Health Care for Low-Income Children: A Compendium, shows how some
states have succeeded in recent years in increasing and stabilizing
Medicaid reimbursement rates at marketplace levels--such as Michigan,
South Carolina and Delaware. The state of Michigan, for example, in
addition to addressing reimbursement concerns, also worked to
creatively improve the delivery of the dental Medicaid program. With
the support of the dental community, the state contracted with Delta
Dental to administer its Medicaid program within 37 counties, naming it
the ``Healthy Kids Dental'' program. The result--a Medicaid program
that functions like a private program, with each Medicaid-eligible
individual bearing a Delta Dental coverage card. The program offers
reimbursement rates at market levels, has eliminated administrative
complexities and functions like a private insurance benefit. Since this
partnership, the number of Michigan Medicaid kids seen by a dentist has
increased from 18 percent to 45 percent. Undoubtedly, this public-
private model is a success story, and there are others. As Congress
contemplates Medicaid reform, the ADA encourages efforts to closely
examine models like the Michigan model, which seek to stabilize a
public insurance program to ensure access to care.
Where state fiscal situations impede increases in provider
reimbursement, state dental societies are working to encourage
improvements in the administration of the Medicaid program. Some
examples are improved case management, transportation services to
assist patients with scheduled appointments and public education on the
importance of oral health. Many dentists have faced years of
frustration with the Medicaid program, resulting in a great deal of
mistrust. Too often the ADA and other dental organizations have heard
their members outline the administrative hassles they face within these
programs. Medicaid bureaucracy through lengthy provider applications,
prior authorization requirements, and complex claims forms deter
provider participation. Congress should ensure that the appropriate
federal agencies work with states to help address this bureaucracy and
improve the system.
Examining the problem, the ADA recommends that Congress consider
the following when addressing Medicaid reform and improving the
coordination of care delivered to those served by the program:
Maintain an EPSDT benefit to ensure state requirements to provide
oral health services to mandatory beneficiaries;
Increase the federal match and/or other funding support for oral
health services;
Encourage and support states in developing and implementing a dental
care delivery system for their Medicaid eligible population
that mirrors the private sector indemnity benefit system.
CONCLUSION
Concerned about the future of the Medicaid program, the ADA is
convening a Symposium in December 2003 to address opportunities for
systemic improvements to the dental Medicaid program. Our goal is to
offer recommendations to Congress and the Administration on dental
Medicaid reform.
Dentists are justifiably proud of the overall state of the nation's
oral health, which, for most Americans, is excellent. But we cannot
forget the fact that millions of people in this country--particularly
low-income children and adults--aren't getting even basic preventive
and restorative dental care. These children and their parents are out
there suffering. There are many dentists out there who want to end that
suffering. Working with Congress and the states, together we must find
the will to break down the barriers that separate them.
______
Prepared Statement of Lawrence A. McAndrews, President and CEO,
National Association of Children's Hospitals
The National Association of Children's Hospitals (N.A.C.H.) is a
not-for-profit trade association, representing more than 120 children's
hospitals across the country. Its members include independent acute
care children's hospitals, acute care children's hospitals organized
within larger medical centers, and independent children's specialty and
rehabilitation hospitals. As the Committee discusses the challenges
facing Medicaid, we appreciate the opportunity to submit this statement
for the record describing the critical role Medicaid plays in the lives
of our nation's children and the ability of children's hospitals to
care for them.
Medicaid is the largest health coverage program for children. It is
important to recognize that Medicaid is the largest single source of
health coverage for children, covering nearly one in four children.
Children comprise more than half of the nation's 50.8 million Medicaid
beneficiaries. As such, the future of Medicaid is of special concern to
children's health, and therefore to the nation's children's hospitals
as well. As hospitals devoted exclusively to the health and well-being
of all children, children's hospitals are integral to the pediatric
health care safety net, providing both inpatient and outpatient care to
a disproportionate share of children enrolled in Medicaid. Although
only 3% of all hospitals, children's hospitals provide nearly 40% of
the hospital care required by the 25.5 million children assisted by
Medicaid.
Medicaid coverage for children is low-cost. Children are a
relatively inexpensive group to cover. In FY 2000, children under 19
(including SSI disabled children) accounted for only 21% of Medicaid
spending. Children's coverage is not fueling the growth in Medicaid
spending. In fact, Medicaid spending for children accounts for only 10%
of the annual growth in total Medicaid spending. In addition, more than
50% of children in Medicaid are already enrolled in managed care plans,
and Medicaid per capita spending for children is comparable to private
coverage.
Medicaid coverage works effectively for children. During the recent
economic downturn, Medicaid has been an important safety net for
children whose parents have lost employer-sponsored coverage. Recently
released U.S. Census Bureau data on the uninsured indicates that the
number and percentage of children (under 18 years of age) without
health insurance did not change in 2002, remaining at 8.5 million or
11.6%. The Census Bureau's report, Health Insurance Coverage in The
United States: 2002, states that a decline in employment-based health
insurance coverage of children was offset by an increase in coverage by
Medicaid and the State Children's Health Insurance Program. The result
suggests that the program--the financing structure of which is designed
to accommodate fluctuations in the economy--is working as intended.
Medicaid's benefits are essential to meet children's unique health
care needs. Medicaid's benefits structure, unlike any other health
insurance program, is designed specifically to meet children's unique
health care needs, including children with special health care needs.
The health care needs of all children are special and distinct from
those of adults, but the term ``children with special health care
needs'' (CSHCN) refers to a group of children who require specialized
health care, habilitation and rehabilitation services. Frequently
children with special health care needs are limited, or have potential
limitations, in their ability to function because of a chronic or
congenital illness, a major trauma, a developmental disability, or
exposure to a serious or life-threatening condition.
For CSHCN, simply having access to health insurance may not be
adequate for their healthcare needs because health insurance policies,
like children, come in all sizes and shapes. Private insurance often
lacks the comprehensive benefits needed by this population, such as
physical and speech therapy, durable medical equipment, behavioral
health services, home health care and some medications. Private
insurance benefits may require that an individual be improving, a
definition that doesn't fit for a child with cerebral palsy who may
need a service to maintain function or a child with a congenital
condition who may need a service to maximize their developmental
potential.
Preservation of the Medicaid program's federal guarantee of
accountability for children's health insurance needs under the Early
and Periodic, Screening, Diagnosis and Treatment (EPSDT) benefit
package is an essential part of sustaining the health care safety net
for children. EPSDT requires that, for children only, states cover all
Medicaid services that are determined to be medically necessary by
their physician during a regularly scheduled EPSDT screening visit.
These can include preventative services, developmental/habilitation
services for very young children, eyeglasses and hearing aids to ensure
that children may learn, as well as prostheses, orthotics and
wheelchairs that can be provided and changed as children grow.
Medicaid affects the ability of children's hospitals to serve all
children. Medicaid is not only the single largest program of public
assistance for children's health care, it is the single largest payer
of care delivered by children's hospitals--paying, on average for
nearly half of the inpatient care provided at children's hospitals.
Children's hospitals also provide the vast majority of inpatient care
required by children with serious illnesses and conditions. For
example, children's hospitals perform 99% of organ transplants and 88%
of cardiac surgeries, and provide 88% of the inpatient care for
children with cystic fibrosis. In some regions, they are the only
source of pediatric specialty care, which makes children's hospitals
essential not only to the children in their own communities but to all
children across the country.
Medicaid generally falls far short of reimbursing children's
hospitals for the cost of providing these essential services. As a
consequence, Medicaid disproportionate share hospital (DSH) payments,
which average more than $6 million per children's hospital, are
extremely important to the financial health of these institutions. In
hospital FY 2001, Medicaid, including DSH payments, on average
reimbursed only 84% of the costs of care in children's hospitals, a
percentage that fell to 76% without DSH payments. This crucial source
of funding for children's hospitals aids in their ability to serve all
children
The specialty and critical care and trauma services that children's
hospitals maintain, including staffing and equipment, carry costs that
are not completely covered. But this ``stand by'' capacity assures that
these services will be there when any child needs them. Because
Medicaid is a vital revenue stream for children's hospitals, any single
reduction in funding presents financial difficulties, which in turn can
lead to curtailing or elimination of programs--programs relied upon not
only by Medicaid-dependent children, but all children.
All children benefit from the work carried out at children's
hospitals--regardless of whether they ever step foot inside their
doors. The nation's children's hospitals serve all children by
fulfilling a variety of critical public needs--training most of our
nation's doctors devoted to children, providing continuing advancements
in children's care, performing some of the most important, cutting-edge
pediatric research and serving as centers of excellence for the sickest
children in the country. Medicaid is a partner in fulfilling those
public needs, and a partner in fulfilling children's hospitals' mission
of providing quality care to all children.
Children should be central to any consideration of the future of
Medicaid. Medicaid plays a special role in not only providing health
insurance for low income Americans but by filling in gaps in other
coverage, whether for Medicare or private insurance. In this capacity,
it is a major payer for long term and home and community-based care, as
well as for mental health services, among others. Any consideration of
Medicaid's future must recognize its many important roles, including
its absolutely critical role in the financing of health care for
children.
______
Prepared Statement of the National Association of Chain Drug Stores
The National Association of Chain Drug Stores (NACDS) appreciates
the opportunity to submit a statement for the record on ``Evaluating
Coordination of Care in Medicaid: Improving Quality and Clinical
Outcomes'' and community pharmacy's role in disease management
programs. NACDS membership consists of 217 retail chain community
pharmacy companies that operate approximately 20,500 traditional chain
drug stores, 15,100 supermarket pharmacies and 6,300 mass merchant
pharmacies. Chain operated community pharmacies fill over 70 percent of
the more than 3 billion prescriptions dispensed in the United States.
COMMUNITY PHARMACY HELPS TO ENHANCE DISEASE STATE MANAGEMENT
Pharmacy and medication therapy services are among the most
commonly used and cost-effective medical interventions in the health
care system. In 2002, over 3 billion prescriptions will be dispensed to
patients by retail pharmacies, with the goal of improving an
individual's health and quality of life.
Pharmacists have a critical role in ensuring the appropriate use of
medications and the management of chronic illness. Pharmacists are most
familiar with a patient's condition and drug regimen, as they often
maintain the only complete and up-to-date record of medication used for
all of a patient's medical conditions. As Congress considers ways to
improve quality and clinical outcomes in Medicaid, it is important for
Medicaid recipients to have access to community pharmacy services, as
well as important disease management services provided by the pharmacy
of their choice.
Many Medicaid recipients could benefit from pharmacy-provided
medication and disease management programs. That is because Medicaid
recipients tend to have more chronic medical conditions requiring
multiple medications, and may lack a medical home. It is crucial to
ensure that disease management programs are accessible and a consistent
part of the patient's routine. The natural choice to consider as the
best manager of disease management programs is the pharmacy. Many
Medicaid recipients may have multiple physicians, but may use the same
pharmacy. The consistent use of the same pharmacy will allow the
pharmacist to track the status of the patient more closely than other
providers or systems.
DEVELOP DISEASE MANAGEMENT PROGRAMS
Medications are safe and effective when used appropriately for the
condition for which they are prescribed. An estimated $177 billion is
spent in health care on hospitalizations and other unnecessary medical
costs such as emergency room visits for non-life threatening
circumstances. These unnecessary medical costs are routinely from
inappropriate or incorrect medication use, including noncompliance of
medication regimen. It is important for Medicaid recipients who rely on
multiple medications for various conditions to understand how to take
their medications to optimize therapy tailored to their particular
condition or disease state.
Those enrolled in Medicaid should have access to a benefit that
includes comprehensive pharmacy services, not just prescription drugs.
Patients with chronic conditions should be guaranteed continuous
coordinated care between each of their health care providers.
A meaningful pharmacy benefit should include important components
such as medication therapy management programs for chronic medical
conditions, refill reminders, extended pharmacist counseling, and
outcomes monitoring and evaluation.
Disease management programs are an essential element of therapeutic
care plans and can help to reduce emergency room visits and hospital
admissions. Preventative measures associated with disease management
can improve the quality of life for patients with chronic conditions
and improve their overall health care outcomes. These programs may be
structured so that those patients most at risk for certain disease
states can be identified and their therapy managed by a pharmacist in
conjunction with their health care providers in an integrated approach
to patient care. Through standardization of definitions, program
components and outcome measures, patients would be assured a minimum
level of clinically accepted services to treat a specific disease
state.
Essential components of a disease management program should
include:
Setting goals for outcomes with the patient;
Improved communication mechanisms between the physician, patient,
pharmacist and other providers;
Documentation and feedback for evaluation of patient progress and
compliance;
Self-management tools and educational materials to aid patients with
behavior modification, compliance, self-monitoring measures and
other preventative measures;
Overall improved access to necessary prescription drugs and other
disease specific services.
PHARMACIST ROLE IN DISEASE MANAGEMENT
Community pharmacies can help increase the pool of health care
providers that will be needed to satisfy the demand for disease
management and treatment programs for Medicaid recipients with chronic
conditions
Pharmacists are familiar with a patient's conditions and drug
regimens due to the pharmacy serving as a frequent point of contact for
many patients. Pharmacies also maintain up-to-date and accurate patient
records, in addition to the readily accessible educational and disease
management tools at the local pharmacy that enhance the patient's self-
management techniques. In fact, many local pharmacies already offer a
variety of disease management services including diabetes self-
management services, asthma and anticoagulation care training.
There are over 50,000 community pharmacies in the country, and many
of them already provide comprehensive pharmacy services that
demonstrate pharmacy's role in improving the quality of life of the
patients they serve. Community pharmacies are therefore a logical place
for disease management to occur.
Through its Medicaid Medication and Disease Management Programs
Pharmacies can:
1. Identify duplicate drug therapies, potential drug-drug and drug-
allergy interactions, and out-of-range dosing, timing, and
routes of administration to avoid serious and costly
complications.
2. Provide comprehensive written information and verbal counseling to
consumers for educational and comprehension purposes to ensure
optimal outcomes.
3. Remind patients to refill their medications when the refill is due
to reduce the incidence of non-compliance with medication
therapy, thus reducing repeated primary care provider office
and emergency room visits.
4. Assist the patient in identifying other activities, such as diet and
exercise, to help manage their condition(s).
In some instances, pharmacy-based disease management services has
gained acceptance in public and private insurance programs. For
example:
Some states reimburse pharmacists for medication therapy and drug
regimen compliance for diabetes, asthma, anticoagulation or
high cholesterol, HIV/AIDS, mental health disorders, and
hypertension.
Some states require health insurance plans to provide some level of
disease management to beneficiaries, and pharmacists may
provide services under these programs. At least six state
statutes specifically reference pharmacists as providers.
Some managed care plans serving Medicaid recipients also privately
contract with community pharmacies to provide diabetes self-
management benefits.
The National Institute for Standards in Pharmacist Credentialing
(NISPC) was established in 1998 to create a consolidated, nationally
recognized, credential for pharmacists seeking certification in a
variety of disease states. Over 1,500 pharmacists have received this
nationally recognized credential in disease specific management. After
having demonstrated the level of clinical competence necessary,
pharmacists develop and supervise successful disease management
programs that offer a wide range of patient and disease specific
services for diabetes, asthma, anticoagulation, or high cholesterol.
The competencies and credentialing standards are based on national
standards developed by experts representing the National Association of
Chain Drug Stores, the National Community Pharmacists Association, the
American Pharmaceutical Association, the National Association of Boards
of Pharmacy and other pharmacy organizations.
Evidence of the value of pharmacists has been published in key
studies that demonstrate the broad range of pharmacist--provided
patient care interventions. These studies have resulted in improved
disease state and drug therapy management, greater patient
satisfaction, improved quality of life and economic savings. For
instance, the Asheville Project began in March 1997 as an effort of the
City of Asheville, a self-insured employer to reduce unnecessary health
care costs. As documented in four articles of the Journal of the
American Pharmaceutical Association, the project resulted in a system
in which pharmacists developed thriving patient care services in their
community pharmacies, with employees, retirees, and dependents with
diabetes experiencing improved A1c levels, lower total health care
costs, fewer days of missed work, and increased satisfaction with
pharmacist's services.
IMPROVING THE CURRENT DISEASE MANAGEMENT SYSTEM
The provision of disease management services and accompanying
payment for these services are as important as providing the drug
product itself. In order to provide continuous quality service to
patients with chronic illnesses, pharmacies must be properly
compensated to cover the costs of providing disease management products
and services. For disease management programs to be effective in the
Medicaid population, pharmacists must be able to be compensated by
Medicaid as other providers do.
Pharmacies continue to seek payment as providers while providing
disease management services to Medicaid recipients. The methods
employed by pharmacists to improve outcomes serve to decrease chronic
illness related health care expenditures.
CONCLUSION
Community pharmacists are the most accessible health care
professionals in many areas of the country. Medicaid beneficiaries
should be able to receive necessary disease state management services
provided by community pharmacists. Any Medicaid disease management
program should provide coverage for such care and allow for the
participation of qualified pharmacists. The program should also allow
beneficiaries to have access to valuable pharmacy-based disease
management and medication therapy management services in addition to
prescription drug products.
We appreciate the opportunity to submit these comments for the
record, and ask that the committee members direct any questions to us
about this statement. Thank you.
______
Prepared Statement of The National Association of Community Health
Centers
The National Association of Community Health Centers (NACHC)
appreciates the opportunity to submit the following statement for the
record on the unique role of health centers and related health center
initiatives to effect positive health outcomes for beneficiaries under
the Medicaid program. NACHC is the advocate voice for our nation's over
1000 Community, Migrant, and Homeless Health Centers and Public Housing
Primary Care Centers, and the patients and communities they serve.
As the Committee gathered from prior NACHC testimony, community
health centers are one of the most important assets we have in
providing high quality, cost-effective, primary and preventive health
care to millions of people living in medically underserved communities
regardless of their ability to pay.
Community health centers play a critical role in building bridges
to better care, and they are an intricate part of the health care
safety net, in place to catch those who fall through the cracks. Health
centers today serve as the family doctor and health care home for 14
million Americans in over 3,400 urban and rural communities across the
country.
One in nine Medicaid recipients, one in six low-income children,
one in eight uninsured individuals, and one in ten rural Americans
benefit from health centers (known in Medicaid law as Federal Qualified
Health Centers, or FQHCs). Among the millions of people served by
health centers:
40% depend on coverage through Medicaid or SCHIP, the State
Children's Health Insurance program;
40% lack health insurance coverage; and
86% are living in families with incomes at or below 200% of the
Federal Poverty Level (FPL).
Moreover, health centers are at the center of a multi-year
initiative to strengthen the health care safety net. Both the Bush
Administration and a bipartisan majority in Congress, led by Chairman
Bilirakis and Ranking Member Brown in the House of Representatives, are
committed to expanding the ability of health centers to reach even more
patients; a combined effort that to date has enabled health centers to
provide care to more than 3 million new people, and that will
eventually increase health center access points by 1,200 over five
years and double the number of people served.
Time and time again, these centers have demonstrated their ability
to provide effective care--reducing infant mortality, decreasing
hospital admissions and lengths of stay. However, as the health care
needs of low-income individuals continue to grow, so do the challenges
to health centers in sustaining their ability to provide quality care
to Medicaid beneficiaries and other patients. Current budget shortfalls
threaten state and local financial support of health centers, even
though their cost of care is among the lowest of all providers.
Reductions in Medicaid eligibility, benefits, and other areas
potentially jeopardize the ability of health centers to continue to
provide care to all patients, including Medicaid patients.Undoubtedly,
for the community health center program to sustain its efforts at
improving the health of the millions of Medicaid beneficiaries and
others it serves, Congress must preserve the program's unique
interrelationship with Medicaid and seek to expand upon the successes
of health centers to effect positive health outcomes.
IMPROVING HEALTH OUTCOMES THROUGH COLLABORATION
A major reason for the success of health centers in improving care
for Medicaid beneficiaries and other individuals is found in the
growing number of health centers participating in a federally-supported
effort called the Health Disparities Collaboratives, aimed at improving
health outcomes for chronic conditions among the medically vulnerable.
Developed by the Health Resource Service Administration (HRSA) Bureau
of Primary Health Care (BPHC), the initiative is structured around the
chronic care model, defined as ``a population-based module that relies
on knowing which patients need care, assuring that they receive
knowledge-based care and actively aids them to participate in their own
care.'' The Collaboratives were designed to cover all chronic illnesses
and, ultimately, prevention as well. Currently, participating health
centers focus on diabetes, cardiovascular disease, asthma, depression,
prevention, cancer, and/or HIV.
Background
The Health Disparities Collaboratives initiative was developed to
change the way health care is delivered--from a provider-oriented to a
patient-, family- and community-oriented system. Patients and
clinicians want a holistic, unified approach that works for both of
them. Since 1998, more than 450 health centers have begun to
participate in the program, and by the end of 2003 the number will
exceed 600, or two-thirds of all health centers--marking significant
progress toward meeting the federal goal of having all BPHC-supported
health centers enrolled in these Collaboratives by 2005.
Purpose
The Collaboratives seek to transform care through a systems model
that identifies and tracks which patients need care for each health
condition, apply the most current clinical knowledge and practice
guidelines to the care that is provided, and actively involve patients
in their own care by educating them on their condition and encouraging
them to set their own health improvement goals. To achieve this last
objective, Collaboratives stress planned individual and group visits to
help patients track their improvement and to continue meeting their
goals. Self-management education has been shown to be more effective
than simply providing information to patients in improving clinical
outcomes, and it possibly reduces costs associated with caring for the
chronic condition.
Vital to the success of the Collaboratives also are patient
registries that improve clinicians' ability to track the course of each
patient's treatment and progress. In a recent case study of five health
centers in various locations throughout the U.S., interviewed center
staff consistently considered these registries as critical in reaching
significant improvements in patient health.
Operation
Health centers operating Collaboratives participate in intensive,
year-long learning and improvement activities. Multi-disciplinary
health center teams attend three learning sessions conducted by the
Institute for Healthcare Improvement under contract to HRSA that use a
performance-based method of learning that supports teams from several
health centers to apply, adapt, share, and generate knowledge about
best practices, and to spread these best practices to other health
centers. By design, the Collaboratives are to be implemented in care
delivery systems quickly and efficiently. In the years following their
intensive learning experience, health center clinical teams disseminate
best practices to other health centers and continue to report progress
on nationally shared measures.
Substantial health center resources are necessary to implement this
model that successfully changes the delivery of chronic care and
improves patient outcomes. Health centers must devote a multi-
disciplinary team of three to five staff members--including a technical
expert knowledgeable in both the subject area and the process of care
and a team leader that oversees the day-to-day operation--ensures that
the program is implemented, and oversees data collection. Data
collection is a critical component of the Collaboratives and requires
extensive development on the part of the health center.
Besides these resources, health centers must also devote valuable
time to implement and administer the initiative. For example, the
health center must allocate at least three to four hours a week in its
already busy schedule for the team to work on the Collaboratives.
Additionally, the team must take time away from the health center to
participate in several learning sessions. These time and resources
requirements fall on already financially strapped health centers seeing
a growing number of patients.
Achievement
Today, almost 25 percent of all health center medical visits are
for chronic conditions--most notably diabetes, hypertension, asthma and
other respiratory illnesses, and heart conditions--or for mental health
problems, and nearly 30 percent of medical encounters are for prenatal
care or for key preventive services, like breast and cervical cancer
screenings, immunizations, and HIV testing. Thus, the ability of the
Collaboratives to improve the health of center patients will
undoubtedly assist in closing the health gaps for the medically
vulnerable in the U.S., and in elevating the quality of care provided
through the centers because:
The health centers are infused with the latest evidenced-based
research and treatment protocols related to each of these
diseases;
Their clinicians are now able to more closely monitor our patients
and provide care that is culturally-competent; and
Their patients are more energized to be even more involved in their
treatment and management of their conditions.
Whether measured in terms of individual health center patients or
large populations, the Collaboratives demonstrate that it is possible
to transform the health care system from one of sickness care to one
that is truly about health care. Collaboratives are powerful drivers
for positive change, through generating improved outcomes faster than
traditional models of training or individual patient-doctor
consultation, and efficiently and effectively translating research into
practice. For example, only two months after the results of a clinical
diabetes prevention trial were reported in the medical literature,
health centers were busy learning how to put the knowledge gained from
the trial into practice.
As a result of the work of the Collaboratives, the Institute of
Medicine commended health centers in a recent report, Fostering Rapid
Advances in Health Care: Learning From System Demonstrations, saying
that their ``strong record in chronic care management, electronic
patient registries and performance measurement . . . contribute to
providing care that is at least as good as, and in many cases superior
to, the overall health system in terms of better quality and lower
costs,'' and recommended health centers as models for reforming the
delivery of primary health care. The General Accounting Office also
recently recognized the Collaboratives as a promising federal program
targeting health disparities that should be expanded.
IMPROVING HEALTH OUTCOMES THROUGH PERFORMANCE MEASURES
The Collaboratives are only the latest advance in a long history of
quality health care delivery by health centers. Numerous studies over
the years have documented that health centers deliver effective, high
quality health care, using both objective and comparative measures of
performance. For example, a recent article in a peer-reviewed journal
examined various health policy studies and reports documenting the
success of health centers in reducing and eliminating health
disparities. Some highlights from the article include the following
important findings:
Medicaid beneficiaries who sought care at health centers were 22
percent less likely to be hospitalized for potentially
avoidable conditions (Ambulatory Care Sensitive Conditions, or
ACSCs) than beneficiaries who obtain care elsewhere, and were
16 percent more likely to have outpatient visits for ACSC-
associated conditions. As a result, health centers have
demonstrated reductions in Medicaid costs of 30 percent to 34
percent, compared with patients receiving care elsewhere.
Prevention and screening services provided at health centers have
been instrumental in reducing disparities. For mammograms,
clinical breast examinations, and up-to-date Pap smears, health
center women far exceed the national rate for comparable women,
and meet or exceed the Healthy People 2010 goals for those
categories.
Even though health center women are more likely to be at greater risk
for adverse pregnancy outcomes, their infant mortality and low
birth weight rates are at or below the national averages for
all women.
Health center practices meet or significantly exceed literature-based
standards for treatment of the most common conditions of
hypertension, acute otitis media, diabetes, and asthma on over
80 percent of the care elements. For example, health center
diabetics were twice as likely to have their glycohemoglobin
tested as scheduled than the national population.
Health center uninsured adults are more likely to receive counseling
on lifestyle issues (such as diet and eating habits, physical
activity, smoking, drinking, and drug use) than uninsured
adults who seek care elsewhere.
reducing disparities in care for medicaid beneficiaries
A study conducted recently by researchers at the George Washington
University Medical Center's School of Public Health and Health Services
found that higher penetration of health centers into states' medically
underserved communities is associated with significant reductions in
minority health disparities. As the number of health centers serving
medically underserved patients grows, this health disparity gap narrows
in such key health indicators as infant mortality, prenatal care,
tuberculosis case rates, and age-adjusted death rates. Significantly,
the study found that comprehensive Medicaid coverage, coupled with the
clinically customized and supported health care provided by health
centers, ``may yield the most effective medical care strategy'' for
reducing disparities in health care for beneficiaries of Medicaid.
The findings from this study add significantly to the already large
and still-growing body of evidence that health centers are doing a
remarkably effective job at providing the right kind of care for
everyone they serve, regardless of race, income, insurance coverage,
location, or primary language.
IMPROVING HEALTH OUTCOMES THROUGH PATIENT NAVIGATION
Community health centers have learned a lot of lessons over the
last forty years of providing health care, one of the important of
which is that it is not enough to open your doors and offer care, but
that you must also reach out to individuals and help them get that
care. To be certain, deeply rooted obstacles to accessing care exist
even when health services and programs, like Medicaid, are
theoretically available and affordable. Poverty, geographic isolation,
cultural and ethnic differences, lack of transportation, low literacy,
lack of knowledge regarding the need for or availability of health
services are all barriers to health and social services for millions of
unserved and underserved Americans. Availability does not equal
utilization.
People who are local, indigenous members and residents of
underserved communities are uniquely knowledgeable about their
population's needs. Where such individuals are already serving as
natural helpers, they communicate to health providers the needs of
community members, provide quality health promotion and disease
prevention information to community members and serve as a crucial link
between their communities and providers to increase utilization of
available preventive health services and to use existing health
services appropriately.
As voices from within the health care system, the job of these
individuals, otherwise known as Patient Navigators, is to bridge gaps
and eliminate disparities in a fragmented system that is often a
challenge too great to overcome--especially among rural, urban,
minority, and medically underserved communities. By guiding patients
through the maze of what can be a sometimes-confusing healthcare
system, especially in the case of Medicaid, patient navigation serves
an effective way to increase access to care and improve health
outcomes.
By their very nature, Patient Navigators are familiar with Medicaid
eligibility requirements, community housing, prescription drug access,
and other programs that might be available to help patients pay for
their treatment, and they would also know whether local community-based
organizations offer ride services in that area for medically
underserved patients to get to their medical appointments.
To be sure, many federal and state programs, like Medicaid, have
been created to aid poor and underserved communities, yet obstacles in
the health care system are still an impediment to care for many
Americans. Patient Navigation can increase efficiency and access--not
by creating new healthcare programs, but by increasing access to health
care and programs that already exist.
For example, the National Breast and Cervical Cancer Early
Detection Program and the National Breast and Cervical Cancer Treatment
Act--programs funded by the federal government and operated in large
part through health centers--enable underserved women to be screened
and treated for breast and cervical cancers. Patient Navigator programs
work within the community health care system to bolster community
outreach and support for these types of programs and to ensure that
eligible women are educated, enrolled, and informed about their
coverage options if diagnosed.
By breaking down barriers associated with accessing the health care
system, Patient Navigator programs can serve as a cornerstone for
federal and state health care initiatives and can improve health
outcomes. As such, Patient Navigators help ensure that the health
resources Congress and State Legislatures have already put into
communities are used effectively.
All told, Patient Navigation programs work to build community
education and trust, but they are also plugged into the community
health care system. This combination allows Patient Navigators to serve
as liaisons for patients between a complex care system and the ultimate
goal--access to quality care and the improvement of health outcomes.
Congress has an opportunity to implement and expand the use of
Patient Navigation in Medicaid and other areas by passing the
bipartisan Patient Navigator, Outreach and Chronic Disease Prevention
Act (S.453/H.R. 918). This legislation would allow communities across
the country to establish community-based patient navigator programs
aimed at improving the health and quality of care received by
individuals, including those under Medicaid.
DELIVERING MEDICAID SAVINGS THROUGH QUALITY CARE
The provision of high-quality health care, with a special,
community-driven focus on the unique health needs--not to mention the
special linguistic and cultural needs--of the populations they serve,
has enabled health centers to deliver savings to all payers, but
especially to Medicaid. According to one recent study, preventable
hospitalizations in communities served by health centers were lower
than in other medically underserved communities not serviced by health
centers. Patients in underserved areas served by these centers had 5.8
fewer preventable hospitalizations per 1,000 people over three years
than those in underserved areas not served by a health center. Several
other studies have found that health centers save the Medicaid program
more than 30 percent in annual spending per beneficiary due to reduced
specialty care referrals and fewer hospital admissions. Based on that
data, it is estimated that health centers already save almost $3
billion annually in combined federal and state Medicaid expenditures.
Of those savings:
$1.8 billion is in reduced federal Medicaid spending, an amount that
exceeds the total of all Medicaid payments to all health
centers last year; and
Over $1.2 billion is in reduced state spending, an amount that is
more than four times the current national total of direct state
funding to health centers across the country.
CONCLUSION
It is clear that health centers could be the foundation for
reforming how states provide health care to the poor, especially in
tough economic times. Time and again, health centers have demonstrated
their ability to generate significant cost savings for Medicaid and
other parts of the health care system, even as they improve the well-
being of their patients and communities. As Congress moves forward on
considering ways in which to reform Medicaid, it is critical that it
keep in mind these health center efforts and successes, and seek to
expand the excellent ability of these centers to effect positive health
outcomes for Medicaid and other medically vulnerable patients.
______
Prepared Statement of Sandeep Wadhwa, MD, MBA, Vice President, Medical
Management Services, McKesson Health Solutions, McKesson Corporation
I am pleased to submit this statement on behalf of McKesson
Corporation to the Subcommittee on Health of the House Committee on
Energy and Commerce, subsequent to the October 15, 2003 hearing on
Evaluating Coordination of Care in Medicaid: Improving Quality and
Clinical Outcomes.
As the world's largest healthcare services company, McKesson is the
industry leader in the provision of disease management services for
state Medicaid programs. As such, we are uniquely positioned to provide
Congress with information on the use of disease management programs to
improve quality and clinical outcomes in the Medicaid population while
decreasing health care costs.
Our disease management clients cover a broad host of purchasers of
health care, including:
State contracts for the Fee-for-Service Medicaid populations in
Mississippi, Washington, Oregon, Colorado, Florida, New
Hampshire, and Montana
Managed Medicaid plans such as Columbia United Providers, Triple-C
(Puerto Rico) and the Santa Clara Family Health Plan
Individual high risk insurance pools like CoverColorado and the
Oklahoma Health Insurance High Risk Pool
Commercial health plans such as Blue Cross Blue Shield Federal
Employees Program and Blue Cross Blue Shield of Texas
Medicare+Choice plans such as Order of Saint Francis and Group Health
Insurance
McKesson is the industry leader in care management services and
software and also has market leadership positions in demand management
and utilization criteria. Furthermore, we are leading providers of
physician and quality profiling software and case management workflow
software. As an early provider of these programs, we have been
delivering disease management services since 1996. McKesson's disease
management programs leverage our experience with patient services,
pharmacy management, and health care quality improvement activities.
Many of these programs and services reflect the capabilities and
expertise of our 170 year old company, one of the largest nationwide
distributors of pharmaceuticals and health care products and the
largest health information technology company in the world.
Over the past two years, many states have turned to disease
management to help address their Medicaid crisis. In particular, the
costs for state Medicaid fee-for-service (FFS) programs are rising
dramatically. The FFS population does not have many of the quality
improvement and cost-control measures available to those enrolled in
Medicaid managed care. The FFS population also has a disproportionate
share of the Supplemental Security Income disabled population. Although
the disabled population is only 17% of the Medicaid population, it
accounts for nearly 40% of its costs.\1\ Care coordination efforts with
a particular focus on the disabled population provide a major
opportunity to improve access to care, empower patients to control
their conditions, enhance the quality of care, and reduce avoidable
Medicaid costs.
---------------------------------------------------------------------------
\1\ Rosenbaum S. ``Medicaid.'' New England Journal of Medicine.
346(8): 635-640. 2002.
---------------------------------------------------------------------------
QUALITY IMPROVEMENT
The care coordination process begins with a comprehensive effort to
identify patients with a chronic illness. Patients are identified
primarily through historical medical claims analysis. This process is
highly efficient and accurate and allows for a comprehensive
population-based identification method rather than relying on costly
and more fallible chart reviews at physicians' offices. Initially, the
physicians of those patients who have been identified are contacted.
Direct mailings then go out to the patients informing them of the
chronic care management program's design and goals. Community based
awareness campaigns also help to raise awareness among patients and
physicians.
Once patients have been identified, enrollment campaigns ensue.
Initial enrollment and assessment takes place telephonically or through
face-to-face meetings with patients. Participation in the programs is
voluntary. In our experience, fewer than 5% of eligible patients have
opted-out of these programs, and the highest rates of participation are
among those who are the sickest, the frailest and the most vulnerable.
Most patients in Medicaid FFS see multiple physicians without one
serving as the primary coordinator of care. The absence of a physician
``quarterback'' contributes to excessive testing, medication errors,
and miscommunications. A key dimension of disease management
interventions is assisting the patient in voluntarily identifying a
``medical home'', which is a physician or a clinic primarily
responsible for treating and managing the patient's chronic condition.
Once a medical home is established, the disease management nurse
cements the relationship by serving as an advocate for the patient and
informing the physician of symptoms, self management practices, and
gaps with nationally accepted clinical guidelines. The quality of the
patient/physician interaction is enhanced through patient education and
nurse advocacy.
In Mississippi, McKesson has partnered with the University of
Mississippi Medical Center (UMC) and with the Mississippi Primary
Health Care Association, the trade organization of community health
centers, to educate providers and beneficiaries about the disease
management initiative. The Mississippi disease management program is
targeted to more than 35,000 Medicaid patients with diabetes, asthma or
high-risk hypertension. Twenty thousand patients are targeted in the
asthma program which is predominately for children whose average age is
12. Approximately 15,000 patients, with an average age of 44, were
identified for the diabetes and high-risk hypertension program. This
partnership, which was launched in the spring of 2003, has been
extremely successful in generating a high level of participation.
Ninety-seven percent of all patients who were contacted for enrollment
agreed to participate in the program.
Another aspect of disease management is addressing the slow
adoption of national clinical practice guidelines in the Medicaid
population. The poor and disabled are more apt to be undertreated than
commercially insured populations. Patients are educated on the
guideline recommendations and encouraged to discuss the appropriateness
of the recommendations with their physicians. McKesson presents reports
to providers on the gaps that exist between practice and guideline
recommendations. Through clinical decision support tools and patient
empowerment, disease management programs are designed to reduce errors
of omission and improve the quality of care. In Mississippi, UMC
physicians reviewed and customized McKesson's protocols to make sure
they were appropriate for Mississippi beneficiaries. For example, UMC
physicians ensured that the terminology and images in the printed
materials were easily understood and culturally appropriate, and that
the program objectives were aligned with the state's standards of care.
CLINICAL OUTCOMES
Improving care coordination, guideline adherence, and patient
education results in improvements in clinical outcomes. This has been
particularly evident in Washington State where McKesson has been
providing disease management services for 21,500 Medicaid beneficiaries
with asthma, diabetes or heart failure since April, 2002.
In just over one year, the program has documented clinical outcome
improvements as well as financial savings to the state. In the asthma
program, which serves 9,500 patients, the flu vaccination rate
increased 28% in one year. The flu vaccine not only prevents asthma
exacerbations, but also reduces costly hospitalizations. Regular use of
anti-inflammatory drugs, which are a key intervention in controlling
the symptoms of asthma patients, increased 14% over the year.
Additionally, the number of patients who used an asthma action plan
more than doubled, from 11% at enrollment to 25% at the end of one
year. An asthma action plan is an important patient guide to self
management and symptom monitoring and can reduce the morbidity
associated with asthma.
Heart failure is largely the consequence of hypertension or heart
damage sustained from heart attacks and is especially prevalent in the
Medicaid disabled population. In the Washington Medicaid heart failure
program, which serves 2,300 patients, the number of patients monitoring
their weight daily increased by 74% in one year. By tracking their
weight on a daily basis, patients with heart failure detect insidious
weight gain, which indicates fluid build-up, and can notify their
doctors before the condition becomes so severe as to threaten breathing
or life. Over the year, hospitalizations in this population have
decreased by over 25%.
The diabetes epidemic linked to increased rates of obesity affects
both disabled adults and overweight children. Adults with diabetes
typically have several related conditions such as high blood pressure,
cholesterol problems, and obesity. The goal of disease management
programs is to improve control of patients' blood sugar levels and also
better manage their other risk factors. In the Washington diabetes
program, which serves 9,600 patients, there was a 33% increase in the
number of patients who knew their hemoglobin A1c level. The hemoglobin
A1c is a key measure of long term sugar control. By teaching the
patient the importance of this number, nurses have encouraged patients
to participate more actively in their care and understand the
physician's treatment goal. There was also a 48% increase in regular
aspirin use in this population of diabetics. Aspirin use has been shown
to dramatically reduce the risk of heart attacks in patients with
diabetes.
These clinical improvements reflect the intense efforts of nurses
to provide patients with the information, strategies, and skills to
gain control of their chronic conditions and to work with their
physicians to reinforce treatment recommendations. Disease management
programs not only provide vulnerable Medicaid populations with nurse
coaching and advocacy support; they also empower patients through
skills and education to be more active participants in their care. In
many instances, McKesson directs the intervention to the caregivers of
the Medicaid patient. The caregiver is often the mother or guardian of
a child with asthma or the spouse or daughter of a Medicaid disabled
patient. These caregivers endure tremendous stress in caring for a
patient, and the disease management nurses provide them with training,
reassurance, support and knowledge to sustain them as effective
caregivers.
BUDGET IMPACT
Perhaps the central barrier to chronic care management in Medicaid
is overcoming the initial costs associated with implementing and
providing these services. While these programs have demonstrated net
cost savings through reductions in avoidable utilization, there are
clearly costs associated with their provision.
Most states are including provisions for guaranteed financial
savings in their Medicaid disease management contracts to ensure that
they are either budget negative or budget neutral, a practice that has
facilitated rapid adoption. If net savings to the state are not
achieved, the disease management program must refund a certain amount
of the fees paid by the state. Third party auditors or evaluation firms
are usually hired by states to verify or conduct their reconciliation
analysis.
The state of Washington program guarantees over $2 million in
savings in the first year of operations, and current estimates from the
state indicate this will be exceeded. Savings from this program largely
arise from reduced hospitalizations and emergency room visits due to
improved disease control. The savings estimate include costs for
implementation and program costs. McKesson and the state of Washington
were recently recognized by the Disease Management Association of
America as the leading Medicaid disease management program, based on
the its evidence of quality improvement and public/private partnership.
RECOMMENDATIONS
Based on McKesson's experience with Medicaid FFS disease management
programs, we would like to offer the following recommendation to the
committee.
1) Federal regulatory barriers impede the ability of states to
utilize disease management services. While managed care innovations are
generally able to be implemented with a 1932(a) amendment to a state's
Medicaid plan, most states have to seek a Medicaid 1915(b) waiver in
order to offer disease management services to that population group.
CMS categorizes disease management as a prepaid ambulatory health plan
(PAHP); however, the 1932(a) exemption does not apply to PAHPs.
Congress can play an important role in expanding the use of disease
management services by addressing the regulatory hurdle to their
adoption in Medicaid.
2) Ambiguity surrounding the payment for disease management
services for those eligible for both Medicaid and Medicare coverage
(e.g. dual eligibles) prevents many states from offering programs that
would benefit this particularly vulnerable and costly population.
Clarification of policies by Congress and CMS would enable states to
provide these needed services to improve care and treatment outcomes
and appropriately reduce costs.
CONCLUSION
McKesson's experience with Medicaid FFS disease management programs
indicates that effective disease management programs lead to improved
quality and clinical outcomes while reducing Medicaid expenditures. The
outcomes-focused, evidence-based interventions provided in disease
management programs improve coordination of care and adherence to
guidelines and empower patients with appropriate knowledge and
resources.
As Congress grapples with improving the quality and delivery of
health care, we support the greater utilization of disease management
programs as a vital way to enhance clinical outcomes for Medicaid
beneficiaries, while concurrently reducing the cost of delivering
better care. We look forward to working with you and members of this
Subcommittee as you address these important concerns.
______
Follow-Up to the Written Testimony of Rhonda M. Medows, M.D., Secretary
of the Agency for Health Care Administration
benefits to beneficiaries
The Florida Medicaid disease management program provides additional
health education and supportive services to beneficiaries living with
chronic disease including diabetes, asthma, heart failure,
hypertension, hemophilia and HIV/AIDS. Each disease state program
provides individualized health education materials, supplemental
medical aids such as blood pressure cuffs and weight scales and nursing
support to the specific population served. At the core of each program
are nurse care managers who work with beneficiaries on a one-on-one
basis, telephonically or face-to-face, to empower participants to
improve their health through behavior and lifestyle changes. The nurse
care managers coordinate care with the beneficiary, the family, the
primary care physician and other community support organizations
involved in the health of the individual. In addition, each program
offers 24/7 access to a nurse, via a toll free number, to every
beneficiary that is eligible for disease management.
The Florida: A Healthy State program (FAHS), part of an innovative
public-private partnership between the Agency for Health Care
Administration and Pfizer Inc. was the first disease management program
to manage multiple disease states. It's community-based program with 60
nurse care managers in 10 hospital systems is also the largest, with
over 115,000 beneficiaries living with diabetes, asthma, hypertension
and heart failure enrolled. The program, now beginning a second term,
has demonstrated success in improved clinical results, lower
utilization of high cost inpatient services and emergency department
visits, which lead to overall cost savings. The table below illustrates
the program impact on utilization at the end of the first year.
----------------------------------------------------------------------------------------------------------------
Heart
Overall Hypertension Asthma Diabetes Failure
----------------------------------------------------------------------------------------------------------------
Inpatient Days............................................ 15. 12.6% 0% >0.7% >13.7% >6.0%
Emergency Room Visits..................................... 0.7 1.0% % >4.0% >1.8% >1.3%
Sample Size............................................... N=3,947 2,014 733 1,003 197
----------------------------------------------------------------------------------------------------------------
This analysis compared the number of emergency department visits and inpatient days in two groups, a) care
managed and b) non-care managed. Claims data from July 2001 to December 2002 was analyzed. To be eligible for
inclusion, both groups had enrollees that were Medicaid eligible continuously from July 2001 to December 2002,
and were matched for eligibility category (SSI vs. TANF), disease state, prior utilization and length of time
in the program.
In addition, population level improvements demonstrate that the
program has successfully educated patients about their disease and
health care, increased their abilities to self-manage, and changed
health-related behaviors. The measurement of these health behaviors is
indicative of the beneficiary's self-management skills, lifestyle
indicators, and perceived quality of life. This data is self-reported
by the beneficiary to the nurse care manager, using nationally
recognized and validated instruments for data collection. A more
detailed description of the instruments is attached, please reference
the attachment ``Self-Management Outcome Measures''.
------------------------------------------------------------------------
Program
Health Behaviors Impact
------------------------------------------------------------------------
Non-Smokers (n=949)........................................ 3.
7%
In Process of Quitting Smoking (n=949)..................... 35
.4%
Following a Special Diet (n=1,720)......................... 14
.0%
Regular Physical Activity (n=982).......................... 13
.9%
Medication Compliance \2\ (n=969).......................... 39
.0%
General Health Status \3\
Physical Health (n=1,834).................................. 3.
4%
Mental Health (n=1,834).................................... 4.
9%
------------------------------------------------------------------------
\1\ N is the number of beneficiaries with an initial health risk
assessment for which a follow-up assessment has been completed. A
response to the question related to the measure at both initial and
follow-up, with a minimum thirty-day period between them, is required.
A total of 12,365 beneficiaries have completed an initial assessment.
\2\ Medication Compliance is measured on a 12-point scale (0=very
compliant, 12=very non-compliant).
\3\ General health status is based on the SF12, a validated measure of
general health status. A higher value indicates better health.
Clinical markers are reported specifically for each disease state
based on nationally recognized clinical treatment guidelines and
standards of care. Examples are:
Asthma
Asthma severity classification (NHLBI Classification)
Peak Flow Meter use
CHF
NYHA Classification (New York Heart Association)
Weight Monitoring
Cholesterol values
Blood Pressure
Diabetes
HbA1c values
Cholesterol values
Blood Glucose
Self foot exams
BMI (Body Mass Index)
Blood Pressure
HTN
Alcohol use
Global Risk score (calculated using CMS data system)
Aspirin use
BMI (Body Mass Index)
Cholesterol values
Blood Pressure Data
A complete report on program impact and outcome measures is
attached. Please reference the documents ``Florida: A Healthy State of
the Program, Summer 2003'' and ``Florida: A Healthy State A Florida
First Health Care Initiative, Program Update, June 2003''.
DATA ANALYSIS
Data management capabilities are one of the most important
components of a quality DM program, and leads to more robust outcome
measurements. In the disease management programs, information is
captured throughout the program to assess improvement processes across
several general domains, including health behaviors, patient self-
management skills, clinical indicators, psychosocial outcomes, and
health care utilization and revolves around three key areas: 1) medical
record information, including laboratory test values, 2) claims data
for inpatient hospitalizations and ED visits and 3) self reported data
from participants. Every effort is made to insure that complete
information is collected from the program participants to insure
adequate statistical power to analyze the relationships between various
intervention components and associated program outcomes.
Health Behaviors--Information about current health behaviors,
including diet, exercise, and smoking status, are captured and stored
in the disease management data system at baseline, at all relevant
follow-up contacts with care managers, and summarized in regular
reports.
Patient Self-Management Skills--To determine whether the program is
positively impacting patients' self-management skills, relevant
information regarding self-monitoring is collected as well. This
includes, but is not limited to self-monitoring of weight for patients
with heart failure, home self-monitoring of blood glucose and daily
foot exams for patients with diabetes, and home blood pressure
monitoring for patients with chronic heart disease. Medication
adherence is also measured at least annually using a 9-item validated
self-report medication compliance scale (Morisky DE, Green LW, Levine
DM. Med Care 1986. Jan:24(1):67-74.).
Clinical Indicators--To determine whether the program has had a
positive impact on patients' health status, a number of clinical
measures are also captured during regular nurse care manager contacts
with program participants including results of laboratory tests, vital
signs, and symptoms. This data is retrieved using a variety of methods,
from patient self-reports, to manual review of the medical record, to a
pilot of home self-testing by beneficiaries, scheduled to begin this
month.
Psychosocial Outcomes--We define psychosocial outcomes as outcomes
that represent influences on patient health-related perceptions and
beliefs. Several indicators of psychosocial improvement are used
throughout the course of the programs including health status, self-
efficacy, and patient satisfaction. The SF-12, a commonly used and
validated instrument to assess health status across all conditions is
administered annually. Self-efficacy regarding self-management for each
disease is also measured via the SF12 to assess patients' confidence in
their ability to do what is necessary to manage their condition. This
kind of efficacy is a powerful measure of patient empowerment, and a
strong predictor of actual health behaviors.
To determine the level of patient and provider satisfaction with
the disease management program, both patient and provider satisfaction
are measured. Included in the measure of patient satisfaction are
questions regarding overall satisfaction with the program, satisfaction
with program staff, usefulness of information received, satisfaction
with assistance with adherence to treatment and self-management plan,
and whether patients would recommend the program to family or friends.
An independent third party consultant was utilized to conduct a
telephonic patient satisfaction survey for the FAHS program. Results
are expected within the next quarter from the University of Florida.
Service Utilization--Claims data is used to collect and analyze
information on service utilization to assess whether the program is
influencing appropriate hospital admissions, number of days in the
hospital, and reducing unnecessary or inappropriate medication and
emergency room use.
POSSIBILITIES FOR IMPROVEMENT OF OUTCOMES MEASUREMENT
There are a number of ways that the Disease Management (DM)
industry can improve our ability to demonstrate the value of DM
programs. Obviously, conducting tightly controlled studies of disease
management would be ideal, but this is not always possible, and almost
always impractical in applied settings. Short of conducting randomized
controlled trials, however, there are approaches that can be used to
better demonstrate the effectiveness of DM programs. The industry is
beginning to see value in sophisticated analytic techniques like time
series analysis, or regression discontinuity designs to evaluate the
savings associated with a program.
Use of the most sensitive and appropriate measures of program
success is critical to accurate outcome reporting. While there have
been a number of recent efforts in the DM industry to develop a
standard set of outcomes measures and metrics for DM programs, to date
there has not been a widely accepted version. Of primary importance is
choosing measures that are sensitive to the change that the program is
hypothesized to effect. These measures include care management
processes and health care delivery processes defined below.
Care Management Processes are specific to the duties performed by
the care managers and include information about patient engagement,
services and assessments performed during all patient contacts, ongoing
monitoring of additional intervention components including patient
support and education, and any other related fulfillment activities
associated with the program.
Health Care Delivery Processes include the actual clinical care
received by the patient including preventive screening and services,
appropriate medication prescribing, and other appropriate medical
procedures and treatments.
ENROLLMENT AND DISENROLLMENT
Patient attrition presents an enormous challenge for the disease
management programs. The mobility of the Medicaid population creates
difficulties in continuity of care and accurate measurement of long
term care management. The two main categories of Medicaid eligibility
for the disease management program are disability (Supplemental
Security Income, SSI) and low income (Temporary Aid for Needy Families,
TANF). The TANF population had approximately 35% of beneficiaries
remaining continuously eligible for the 12-month period of FY 2001-
20002. The SSI population presents a more stable pattern of eligibility
with approximately 71% remaining eligible for the same 12-month period.
The transient nature of the patient population's residence status
presents large challenges for acquiring and maintaining communication
with patients as well. Approximately 40% of beneficiary contact
information is incorrect, creating a challenge for the disease
management program to find beneficiaries and to actively engage them.
Medicaid is working on system enhancements to improve the contact
information. The disease management programs have added resources to
increase the number of beneficiaries contacted, including on the ground
personnel to literally go house to house to share program information,
software packages that enable the program to gain correct phone number
information, and radio and print media designed to increase awareness
of the program.
Beneficiaries identified through claims data as being eligible for
disease management due to disease state condition are automatically
enrolled in the program and may opt-out at any point they desire. They
may re-enroll at any time as well. Beneficiaries who lose Medicaid
eligibility are disenrolled, and re-enrolled when eligibility is
regained. Due to this high volume churn of eligibility, the disease
management programs now leave beneficiaries on the census list for 60
days after loss of eligibility, at no charge to the Agency, to improve
continuity of care as many will re-gain eligibility and return to the
program. In the FAHS program, care managed patients have been in the
program an average of 445 days. Disenrolled patients were enrolled for
an average of 329 days.
------------------------------------------------------------------------
Average
Total Days in
Beneficiaries Program
------------------------------------------------------------------------
Current FAHS Enrollees...................... 89,061 445
Beneficiaries Disenrolled................... 40,477 329
------------------------------------------------------------------------
Note: Based on beneficiaries enrolled as of November 5, 2003
An example of enrollment and disenrollment statistics for the FAHS
program is outlined in the table below.
----------------------------------------------------------------------------------------------------------------
2001Q4 2002Q1 2002Q2 2002Q3 2002Q4 2003Q1 2003Q2 2003Q3
----------------------------------------------------------------------------------------------------------------
New Enrollments................. 35,774 24,882 32 27,537 9,763 9,286 15,384 6,844
Re-enrollments.................. 1 31 5,208 6,004 1,276 2,586 10,509 12,257
Disenrollments.................. 5 126 12,430 13,408 6,891 9,883 16,507 18,840
Cumulative (end of quarter)... 35,770 60,557 53,367 73,500 77,648 79,637 89,023 89,284
----------------------------------------------------------------------------------------------------------------
Enrollment, disenrollment, re-enrollment and cumulative enrollment statistics by quarter extracted from Pfizer
Health Solutions' Clinical Management System (CMS') software.
Note: Patients disenrolled can be re-enrolled within the same quarter, even on the same day; these numbers do
not represent mutually exclusive individuals.
ADDRESSING CULTURAL AND HEALTH LITERACY NEEDS
Each Florida Medicaid DM program strives to provide low literacy,
culturally competent educational materials in English, Spanish and
Haitian-Creole. Each vendor utilizes a universal telephonic translation
line and has bi-lingual nurse care managers who interact with
beneficiaries in their native language when possible.
In addition, a second initiative of the Pfizer-Florida Medicaid
partnership is a comprehensive health literacy study and intervention.
The study was conducted in association with the University of South
Florida (USF) and 27 Federally Qualified Health Centers. Health
Literacy is the ability to read, understand, and effectively use health
care information and follow instructions from health professionals. The
Florida Health Literacy Study investigates the direct effects of the
health literacy interventions on patient disease knowledge, self-care
behaviors and the management of their Type 2 diabetes and/or
hypertension. The study will also estimate the indirect effects of
these interventions on disease complications and, ultimately, health
care costs. The study is the first of its magnitude on health literacy
and is detailed below:
27 Federally Qualified Health Centers (FQHC) are Participating: 14
are intervention sites, 13 are control sites. 14 Health
Educators were hired and trained to provide group and one-on-
one educational sessions using diabetes and hypertension
materials in English and Spanish. Educational materials were
available free of charge to Medicaid beneficiaries with Type 2
diabetes or hypertension at 60 community health center sites,
33 of which are non-study sites.
Enrollment (as of February 2003): 679 at the intervention sites; 325
at the control sites
Status: The study ended in May 2003 with a 6-month follow-up to occur
in November 2003 and results are expected from the University
of South Florida in first quarter 2004.
Pfizer Health Solutions underwrote two key market research projects
that marked the beginning of the Florida: A Healthy State program and
provided important information about the health care delivery in
Florida and the patterns of utilization of the MediPass population.
These include:
The Physician Market Research (2002)
Patient Market Research (2002)
The physician market research provided an interesting perspective
on the issues and challenges faced by practitioners caring for
chronically ill Medicaid patients. This feedback helped FAHS understand
the intricate relationship between the social, economic, linguistic and
cultural problems affecting these patients and their overall health
status.
The patient market research followed in an attempt to better
understand the needs of the patients served by Florida: A Healthy
State. The project targeted Medicaid beneficiaries representing all
races and ethnic groups. These included: Whites, African Americans,
Hispanics, and Haitians. The purpose of this project was to assess:
Experiences with the health care system
Effective/culturally appropriate channels of communications to
disseminate information about the program and encourage
patients to enroll.
Through this research it was learned that some ethnic groups value
health differently and that cultural relevancy is extremely important
when communicating information about health choices and personal care.
These findings led to modification of all program materials to conform
to the needs of the patients enrolled in FAHS:
This included:
1. Re-designing patients materials for cultural relevancy, language and
literacy level: Bilingual program letters; Bilingual patient
brochures; and Awareness campaigns (free flu shots coupons,
magnetic calendars . . .)
2. Re-designing care management protocols: Spanish-speaking care
managers available on triage line; Bilingual care managers
working extended hours (Spanish, English, Haitian/Creole); AT&T
translators; and Hospital staff translators
3. Ongoing efforts include: Developing bilingual patient education
materials that meet Health Literacy principles and are written
at 4th grade level. Assessing the educational needs of the
patients and making health information available in various
formats and different venues.
4. Dissiminating program information through culturally appropriate
trusted sources: Medicaid Offices--e.g., health fairs; Department of
Children and Families--e.g., services for low-income and disadvantaged
populations; Community based organizations--e.g., groups like Little
Havana Nutrition Education Center, Community Voices Miami (coalition of
health and social services organizations), federally qualified
community health centers, child care agencies, area health education
centers; Advocacy Groups--e.g., (American Heart Association, American
Lung Association, American Diabetes Association), LULAC; Faith-Based
Organizations/Churches--e.g., Diabetes Sundays, Lectures, Radio Shows,
Church Bulletins; Government agencies--e.g., Department of Health and
county health clinics, Department of Elder Affairs; Municipalities--
e.g., City of Hialeah centers (large Hispanic population), City of
Miami and others; Schools--e.g., County School Boards, Pediatric Asthma
Programs
5. Developing a Statewide Community Resource Directory with relevant
health and social information for nurse care managers, Medicaid
Area Office staff use.
The Health Choice Network program represents an innovative Bristol-
Myers Squibb funded program of faith based, culturally competent care
for Medicaid beneficiaries with diabetes and depression. This community
based care management program entitled Diabetik SMART is active in 8
Federally Qualified Health Centers and 50 community sites, with the
faith-based outreach component involving 9 predominantly African-
American and Hispanic Churches. This unique program utilizes
Promotoras, or culturally appropriate lay health workers, to enhance
disease management services to beneficiaries. The Promotoras, trained
and supervised by registered nurses, interact with the beneficiaries,
lead educational sessions and provide educational materials to actively
engaged beneficiaries. Over 1,741 beneficiaries were identified as
eligible, with 494 actively engaged in the program in its first year of
operation. Evaluation of the program will be conducted by the
University of Florida and will measure the relationship of improved
health behavior, as indicated by a lower Hemoglobin A1c, to direct
health care costs. The program has not been fully operational for the
time necessary to accurately measure changes in health behavior, and
results are expected in 2004.
Complementing these other disease management initiatives, the
Medicaid Area Office staff organized a series of quarterly outreach
campaigns partnering with the faith based community and interfaced with
a Medicaid newsletter in an effort to educate and empower Medicaid
beneficiaries to make better health care choices. The newsletters are
printed in English, Spanish and Haitian-Creole and distributed to
various local community agencies and other state agencies to raise
awareness of health care issues. Each quarter has a designated theme
such as ``Diabetes Sunday'', during which Area Office staff worked with
local pastors to hold health fairs and screening after Sunday services
at predominantly African-American and Hispanic Churches in an effort to
raise awareness of diabetes and the importance of screening and
treatment. ``A Child Primer'' focused on back-to-school issues, such as
immunizations and child health check-ups; ``Healthy Aging'' focused on
elders and health care. ``Managing Chronic Illnesses'' is the current
quarter's theme in which Area Office staff partner with the local faith
based community and provide health information and outreach activities
in churches on illnesses such as diabetes, breast cancer, hypertension,
heart failure and even AIDS. Up next is ``Healthy Bodies, Healthy
Minds'' with a focus on managing stress, mental health, healthy eating
habits, physical fitness and well health exams. Copies of the
newsletters are attached.
The Area Office staff have also been involved with a number of
other efforts including outreach activities sponsored by the Agency
Community Resource Office, the Minority Health Awareness Committee and
most recently partnering with The Center for Medicare/Medicaid via
First Coast Service Options, Inc. to reach individuals in communities
challenged by low income, low literacy and location. Medicare and
Medicaid information was provided to these individuals in Spanish,
Creole and English.
Area Office staff have completed more than 2,000 education/outreach
activities reaching a total of more than 200,000 individuals. Of this
total more than 300 education outreach activities were completed beyond
normal working hours. Education and outreach efforts are also a part of
interaction with Medicaid beneficiaries as staff assists them in
navigating the health care system. Publications are sent directly to
beneficiaries when responding to correspondence and as a result of
telephone calls received. The Medicaid Area Offices are actively,
thoroughly and willingly involved with the community to reach
culturally diverse groups of beneficiaries and individuals.
Outside the scope of the disease management program, the Agency has
contracted with Florida A&M University's Institute of Public Health
College of Pharmacy and Pharmaceutical Sciences to conduct an objective
demographic study of Florida's Medicaid population in the interest of
facilitating the development of improved service delivery models,
health promotion activities and improved communication between
beneficiaries and the Agency. This study will utilize (1) the analysis
of existing Medicaid data and reports and (2) the collection of primary
data to supplement existing knowledge including telephonic surveys.
Completion of the study is expected in early 2004.
In closing, Florida Medicaid's disease management programs have
demonstrated successes in improving the health of beneficiaries
enrolled by empowering them to make better health behavior choices
leading to clinical improvement of their existing chronic illness and
in turn, reducing health care costs. We look forward to a continued
reporting of favorable outcome measures and positive impact on the
lives of Medicaid beneficiaries statewide.