Chronic Care Management: Options for Vermont

November 14-15, 2005 Montpelier, VT

Chronic Care Management: Options for Vermont

Kenneth E. Thorpe, Ph.D.Robert W. Woodruff Professor and Chair

Department of Health Policy and ManagementRollins School of Public Health

Emory [email protected]


Key Facts• Cost of treating chronically ill patients accounts for

75% of health spending in Vermont (over $3 Billion per year)

• Rise in chronic illnesses and obesity key factors in driving growth in spending

• Chronically ill patients receive about 50% of the clinically recommended care

• The IOM and others have highlighted the need to dramatically restructure how we deliver services– Patient focused/central– “integrated” multi-disciplinary approach– Proactive not reactive model


Chronic Care Model (CCM):1. Does It Work?

• Yes. Interventions that contain 1 or more elements of the chronic care model improve clinical outcomes and processes and to lesser extent quality of life according to RAND findings.

2. Implementation Challenges Facing The State: Can Vermont Build the CCM?

• Change how Medicaid pays for care—key challenge for existing Blueprint.


Disease States Commonly Targeted by DM Industry• CHF, Cardiovascular disease• Asthma• Chronic Obstructive Pulmonary Disease

(COPD)• Diabetes• Cancer• Maternal/Neonatal• Rare Diseases• ESRD


Components of DM ProductsPopulation ScreeningUsing claims/clinical data to identify patients for disease management

Patient Risk ManagementSurveying patients about disease status/burden to identify for disease management

Team-Based CareUsing formalized teams to increase collaboration of care

Alternative EncountersProviding opportunities outside of the face-to-face encounter for relationship

Cross-Consortium CoordinationManaging across sites and settings to improve care continuity

Patient EducationTeaching patients about their disease

Outreach/Case ManagementTracking patients and their status proactively

Decision Support At the Point of CareTranslating disease management guidelines to patients-specific recommendations for clinicians.

Guidelines/ProtocolProviding information to clinicians on recommended clinical management

Performance FeedbackMeasuring performance in delivering desired care and achieving improved outcomes


Full Integration: Population Based and Chronic Care Case Based Model

Lifestyle interventions

Low risk At risk DiseaseManagementDiseaseSymptomsEarly Signs

Preventive Services Case Management

Screening

Primary and SecondaryPrevention

Acutetreatment

DiseaseManagement

HEALTH IMPROVEMENTDISEASE MANAGEMENT

HEALTH MANAGEMENT

POPULATION-BASED CASE-BASED


Disease Management Targets for Vermont• Medicaid, could be effective approach

for managing global commitment• State employees• Dual eligible (Medicaid/Medicare)• Commercial market


Managed Care Organizations (MCOs) Play Key Role In Medicaid DM Nationally• Some MCOs manage directly, others

outsource and pay vendors on performance (e.g. % reduction in hemoglobin A/C levels among diabetics, % reduction in hospital days among asthmatics)

• Disease states typically targeted in Medicaid– depression - anxiety disorders– psychosis - diabetes– hypertension - asthma– CHF, CVD


Other states are implementing disease management programs to provide beneficiaries with higher quality care at a lower cost• Florida – runs in AIDS, Congestive Heart Failure (CHF),

End Stage Renal Disease (ESRD), diabetes, hemophilia and asthma. Five of these programs reported successful results

• Washington state runs programs in ESRD, diabetes, asthma and CHF and has also published favorable results.

• Montana started recently with five common chronic diseases and a highly popular nurse call in line to help beneficiaries coordinate care.

• Indiana is building its own program rather than outsourcing to disease management vendors.

• Wyoming, Texas, New Hampshire, Georgia, Tennessee, and South Carolina are in various stages of RFPs with disease management vendors and will likely begin operations soon.


Selected Examples of DM in Medicaid FFS

State

DM Program Focus

Years in Operation

Florida Asthma, CHF, HIV/AIDS, Hemophilia, ESRD, Diabetes, Hypertension, Depression

1998-present

Mississippi Asthma, Diabetes, Hyperlipidemia, Coagulation Disorders

1998 – present

North Carolina

Asthma, Diabetes, LTC Polypharmacy 1998 – present

Virginia Asthma, Diabetes, Ulcers, GERD, CHF, COPD

Asthma Pilot; 1995-1997; All Others: 1997-present

Washington Asthma, CHF, Diabetes, ESRD, Other High Cost Patient Populations

2002-present


DM Contracting Examples• Washington - full risk

– 80% payment at risk based on projected savings– 20% payment at risk based on

performance/quality– Has been effective in Washington

• Financial and clinical goals need to be clear• Need methodology for program evaluation


Based on other states’ experience and vendor guarantees, significant savings can be achieved, e.g.,• Disabled and Blind – 4%• Aged – Community & Custodial Care

– Acute Care Medical – 25%– Drugs – 10%– Aged in Skilled Nursing – 20%– TANF – Neonates – 6%– ESRD – 8%

Contracts typically include performance guarantees. States typically pay base administrative fees to DSM vendors. At the end of the reporting period (Usually a Fiscal year), savings are measured. If the net savings “guarantee” is not met, the vendor will reimburse the state up to 100% of their administrative fees.SOURCE: COMPUTER SCIENCES CORPORATION


Vermont can expect challenges to implementing these programs• Need continuous enrollment (at least

12 monthly enrollment by Medicaid / SCHIP) populations

• Need to define business model:– Per member, per month adjusted for risk

(i.e. Medicare Advantage Methods).– Contracts with physician groups based in

cost savings / quality / clinical measures


Inside the “Black Box”: Key Implementation Issues1. How to identify candidates

• Registry• Claims data• Physician referral

2. How to enroll beneficiaries• “opt-in” (low enrollment ≈ 30%)• “engagement or opt-out model” (are enrolled

unless they decline – up to 95% participation)


Inside the “Black Box”: Key Implementation Issues3. How to pay for DM – Perhaps the

Key Issue• Full insurance risk (PMPM risk adjusted

payment using Medicare Advantage Model)

• P4P – Performance Risk• Define evidence based guidelines


Inside the “Black Box”: Key Implementation Issues• P4P (continued)

– Bonus pool distribution at practical network level based on

• HEDIS measures (50% weight)• Patient satisfaction (30% weight)• IT investment (20% weight)

Chronic Care Management: Options for Vermont

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