Transcript 2008_SCI_Summer_Meeting_Chronic Disease Management

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
 Primarily fee-for-service
 Voluntary managed care in Cook and seven
other rural counties (170,000 members)
Program Goals
• 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)
– Improve coordination of care
– Increase member compliance with treatment
plan and improve self-management skills
– Improve adherence to national, evidencebased clinical practice guidelines
– Use data and IT tools to better monitor,
report and improve clinical outcomes
Overview
 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 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 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
Members
Schizophrenia
13.8%
• Disease state shown by primary
Other Psychoses
diagnosis:
Other / Substance Abuse
0.5%
Osteoarthritis
0.7%
0.9%
– Over 26% of members have Hypertension
3.8%
Hemophilia
a primary diagnosis within
0.0%
the core five conditions
Heart Failure
7.1%
(Asthma, Diabetes, COPD,
Headache
0.6%
CAD, CHF)
HIV-AIDS
– Over 22% of members have 3.1%
Fibromyalgia
a primary diagnosis of a
0.1%
End Stage Renal Disease
behavioral health condition
1.6%
– A significant portion of
Dyslipidemia
3.8%
members suffer from
Diabetes
4.3%
multiple co-morbidities
Developmental Delay NOS
2.3%
Depression
1.4%
Coronary Artery Disease
3.3%
Transplants
Traumatic Brain Injury
0.5%
0.0%
Other Conditions
29.2%
Asthma
6.1%
Back Pain
1.2%
Bipolar
7.1%
Cancer
2.1%
Chronic Fatigue Syndrome
0.1%
Chronic Kidney Disease
0.6%
Chronic Obstructive
Pulmonary Disease
5.8%
DM Patient Activation
Strategy
 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 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 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
Management 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 followup.
 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
Provider 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 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 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 Portal
Provider Roster
PCP 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 Profile
Provider Profile
Claims 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 History
PCP 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)

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 Education

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
Success
 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 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
(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 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)
• 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 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%