july 30 – august 1, 2008 stephen e. saunders, m.d., m.p.h medicaid medical advisor
DESCRIPTION
ILLINOIS DISEASE MANAGEMENT MEDICAL HOME INITIATIVE State Coverage Initiatives Summer Workshop for State Officials San Francisco, California. July 30 – August 1, 2008 Stephen E. Saunders, M.D., M.P.H Medicaid Medical Advisor. Illinois Background. 2.3 Million beneficiaries in HFS programs - PowerPoint PPT PresentationTRANSCRIPT
ILLINOIS DISEASE MANAGEMENT ILLINOIS DISEASE MANAGEMENT MEDICAL HOME INITIATIVEMEDICAL HOME INITIATIVE
State Coverage Initiatives Summer State Coverage Initiatives Summer Workshop for State OfficialsWorkshop for State Officials
San Francisco, California
July 30 – August 1, 2008Stephen E. Saunders, M.D., M.P.H
Medicaid Medical Advisor
Illinois BackgroundIllinois Background
2.3 Million beneficiaries in HFS programs
Primarily fee-for-service
Voluntary managed care in Cook and seven other rural counties (170,000 members)
Program Program GoalsGoals
• Goal– Improve health outcomes & reduce avoidable
costs
• Program Design Concepts– Reduce inappropriate and unnecessary
utilization, especially ED use– Reduce avoidable medical admissions through
better community-based care– Establish a medical home to minimize
fragmented care and improve continuity of care
Program Goals (2)Program Goals (2)
– Improve coordination of care– Increase member compliance with
treatment plan and improve self-management skills
– Improve adherence to national, evidence-based clinical practice guidelines
– Use data and IT tools to better monitor, report and improve clinical outcomes
OverviewOverview
Primary Care Case Management PCCM Administrator responsible for provider
recruitment, client enrollment, quality and EPSDT compliance.
Program designed to ensure Medical Home 1.7 million beneficiaries eligible
Disease Management population is a subset 220 beneficiaries eligible Targets disabled adults and children with
asthma
Program StatusProgram Status
PCCM Network development began in Fall 2006
Started member enrollment for Cook County in February 2007
Current status Statewide enrollment complete 1.6 million members enrolled 5,300 medical homes (physicians and
clinics) with over 5 million member capacity
DM program administrator started July, 2006.
Disease ManagementDisease Management
Eligibility
Disabled Adults: All eligible irrespective of disease or condition – 122,000
Persistent Asthma: Children and adults who have persistent asthma (utilizing the HEDIS definition) - 75,000
Frequent ER Users: Children and adults who are frequent emergency room users (defined as 6 or more visits a year) - 32,000
Participation in Your Healthcare PlusTM is voluntary, and statewide. Individuals can “opt out.”
Disease State of Eligible Disease State of Eligible MembersMembers
Other Conditions29.2%
Asthma6.1%
Back Pain1.2%
Bipolar7.1%
Cancer2.1%
Chronic Fatigue Syndrome0.1%
Chronic Kidney Disease0.6%
Chronic Obstructive Pulmonary Disease
5.8%Coronary Artery Disease3.3%
Depression1.4%
Developmental Delay NOS2.3%
Diabetes4.3%
Dyslipidemia3.8%
End Stage Renal Disease1.6%
Fibromyalgia0.1%
HIV-AIDS3.1%
Headache0.6%
Heart Failure7.1%
Hemophilia0.0%
Hypertension3.8%
Osteoarthritis0.9%
Other / Substance Abuse0.7%
Other Psychoses0.5%
Schizophrenia13.8%
Transplants0.5%
Traumatic Brain Injury0.0%
• Disease state shown by primary diagnosis:– Over 26% of members
have a primary diagnosis within the core five conditions (Asthma, Diabetes, COPD, CAD, CHF)
– Over 22% of members have a primary diagnosis of a behavioral health condition
– A significant portion of members suffer from multiple co-morbidities
DM Patient Activation DM Patient Activation StrategyStrategy
Community based teams of professional and lay educators – 170 local staff
Teams are comprised of individuals who are indigenous to these communities, culturally diverse
Staff is also placed in high volume sites (hospitals and clinics)
Other special projects to augment this effort
DM Program ModelDM Program Model Community Staff
Nurse
Lay community educators
Social workers
Behavioral health workers
Hospital based case managers
Clinic based staff
Special Projects
LTC initiatives
Pharmacy
Behavioral health
Services to HFS ClientsServices to HFS Clients
• Health Risk Assessment - to determine disease severity and knowledge of self-management and care practices
• Care Plan - to identify problems, goals and interventions specific to each client
• Ongoing Case Management - dependent on risk level with highest risk receiving monthly nurse case manager assistance
• Health Education - relative to medical conditions
• Level of Services – dependent on Risk stratification
PCP Support for Disease PCP Support for Disease Management MembersManagement Members
Support providers care plan by facilitating patient compliance.
Nurses to provide education to patients with chronic conditions to help them better understand their disease, follow care plan and medication requirements.
Nurses to provide intensive care management to most complex patients.
Support provider in post ER and hospitalization follow-up.
Notify provider of any urgent medical problem or medication management/compliance issues.
Physicians receive support in identifying patients with unusual drug utilization patterns
PCCM Program PCCM Program Provider ReimbursementProvider Reimbursement
PCPs are paid a PMPM month for every person whose care they are responsible to manage: $2.00 per child $3.00 per parent $4.00 per disabled or elderly enrollee
The monthly care management fee is paid even if the enrollee does not get services that month. PCPs will continue to receive their regular
fee for service reimbursement for services from HFS.
PCP RequirementsPCP Requirements
Maintain hospital admitting and/or delivery privileges or have arrangements for admission
Make medically necessary referrals to HFS enrolled providers, including specialists, as needed
Provide direct access to enrollees through an answering service/paging mechanism or other approved arrangement for coverage 24 hours a day, 7 days a week. Automatic referral to an emergency room does not qualify
Maintain office hours of at least 24 hours/week (solo practices) or 32 hours/week (group practices)
Follow recognized preventive care guidelines Manage chronic disease Appointment scheduling guidelines.
PCP SUPPORTPCP SUPPORT• PCP access to secure web portal which contains
PCP support materials
• Patient roster
• Mailed monthly but also available electronically
• Provides information on needed preventive services
• Well child visits
• Pap smears
• Mammograms
• Electronic version sortable
Provider PortalProvider Portal
Provider RosterProvider Roster
PCP SupportPCP Support Provider profiles
20 HEDIS and HEDIS-like metrics
System and provider specific performance
Listing of members with chronic diseases and their level of metric compliance.
Historical claims
2 years Medicaid claims
Pharmacy
Immunizations (7 years of data)
Office visits
Hospitalization
Diagnosis
Procedures
Provider ProfileProvider Profile
Provider ProfileProvider Profile
Claims HistoryClaims History Prescription Summary
Prescription Date Prescription Quantity Prescription Description
Immunization Summary Immunization Date Immunization Code Immunization Description
Claim Summary Service Date Claim Date Provider Name Diagnosis Code Procedure Code Claim Type
Claims HistoryClaims History
PCP SupportPCP Support
Pay for Performance
Bonus payment for meeting National 50th HEDIS percentile.
Measures
Immunizations
Developmental Screening
Asthma Management
Diabetes Management (HbAIC)
Mammograms
EPSDT (Well Child)
PCP Support - (continued)PCP Support - (continued) Provider Services Representatives
11 Provider Services Reps in field
Provider Services Help desk – 1-877-912-1999
Outreach and Education to support Providers and their staff
Site Visits
Training Sessions
Billing
EPSDT Support
Quality Assurance
Monthly Webinars
Specialty Resource Database
Provider Newsletter and web site
Provider Continuing Provider Continuing EducationEducation
Education program provided by AAP and AFP under subcontract.
Continuing Medical Education programs on evidence-based evaluation and management of common chronic conditions.
Chronic Care Model
Asthma
Depression
Diabetes
COPD
Substance Abuse
Topics also include preventive health
Immunizations
Developmental Assessment
Medical Home
In-Office training for physician and staff in addition to traditional CME.
Measures of DM Program Measures of DM Program SuccessSuccess
Patient and provider satisfaction (survey)
Reductions in avoidable hospitalization, ED visits
Calculated cost avoidance relative to preprogram cost trends
Improvements in state defined clinical indicators
Heart Failure: Percent of pts on ACE/ARB medication
Diabetes: Retinal exam, HgbA1c testing rates
CAD: Cholesterol testing rates, Statins,
ACE/ARB
Asthma: Use of controller medications
COPD: Use of spirometry for dx, corticosteroids
post exacerbation
PCCM Quality MeasuresPCCM Quality Measures Childhood immunizations
Lead testing
Developmental screening
Appropriate medications asthma, diabetes
care (HbA1c)
Well baby/well child visits
Cervical cancer screening
Breast cancer screening
PCCM Quality Measures PCCM Quality Measures (Continued)(Continued)
Adolescent well care Prenatal care frequency/timeliness Post partum care Depression treatment Adult access to preventive care ER visits/1000 Ambulatory care sensitive hospital visits
Lessons LearnedLessons Learned
• Difficult to find high risk members – especially Chicago
• Mental Health is a significant problem both as a primary diagnosis and as co-morbidity
• Behavioral health component requires specialized focus and outreach
• Importance of interagency coordination, especially behavioral health
• Importance of physician buy in and need for provider input
Lessons Learned (2)Lessons Learned (2)
• Delayed launch of PCCM program made launching DM program more difficult
• Need ability to analyze claims data rapidly
• LTC community very different and more difficult to engage
• Interventions, program components staggered during program launch – some components take longer than anticipated
• Avoid promising significant savings in year one
RESULTS: Year 1RESULTS: Year 1
• $34 million net savings• Reduction in hospitalization costs (9%)• Provider and patient satisfaction
• 94% members satisfied or very satisfied• 65% providers report program useful and 70% would recommend
their patients participate• Modest improvement in clinical metrics• Disease specific hospital admission rate decreases
• CAD - 20%• CHF - 19%• Asthma - 19%