november 14-15, 2005 montpelier, vt chronic care management: options for vermont kenneth e. thorpe,...
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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]
November 14-15, 2005 Montpelier, VT
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
November 14-15, 2005 Montpelier, VT
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.
November 14-15, 2005 Montpelier, VT
Disease States Commonly Targeted by DM Industry• CHF, Cardiovascular disease• Asthma• Chronic Obstructive Pulmonary Disease
(COPD)• Diabetes• Cancer• Maternal/Neonatal• Rare Diseases• ESRD
November 14-15, 2005 Montpelier, VT
Components of DM ProductsPopulation Screening
Using claims/clinical data to identify patients for disease management
Patient Risk Management
Surveying patients about disease status/burden to identify for disease management
Team-Based Care
Using formalized teams to increase collaboration of care
Alternative Encounters
Providing opportunities outside of the face-to-face encounter for relationship
Cross-Consortium Coordination
Managing across sites and settings to improve care continuity
Patient Education
Teaching patients about their disease
Outreach/Case Management
Tracking patients and their status proactively
Decision Support At the Point of Care
Translating disease management guidelines to patients-specific recommendations for clinicians.
Guidelines/Protocol
Providing information to clinicians on recommended clinical management
Performance Feedback
Measuring performance in delivering desired care and achieving improved outcomes
November 14-15, 2005 Montpelier, VT
Full Integration: Population Based and Chronic Care Case Based Model
Lifestyle interventions
Low risk At riskDisease
ManagementDiseaseSymptomsEarly Signs
Preventive Services Case Management
Screening
Primary and SecondaryPrevention
Acutetreatment
DiseaseManagement
HEALTH IMPROVEMENTDISEASE MANAGEMENT
HEALTH MANAGEMENT
POPULATION-BASED CASE-BASED
November 14-15, 2005 Montpelier, VT
Disease Management Targets for Vermont• Medicaid, could be effective approach
for managing global commitment
• State employees
• Dual eligible (Medicaid/Medicare)
• Commercial market
November 14-15, 2005 Montpelier, VT
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
November 14-15, 2005 Montpelier, VT
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.
November 14-15, 2005 Montpelier, VT
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
November 14-15, 2005 Montpelier, VT
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
November 14-15, 2005 Montpelier, VT
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
November 14-15, 2005 Montpelier, VT
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
November 14-15, 2005 Montpelier, VT
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)
November 14-15, 2005 Montpelier, VT
Inside the “Black Box”: Key Implementation Issues
3. 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
November 14-15, 2005 Montpelier, VT
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)