texas health and human services commission
TRANSCRIPT
Texas Health and Human Services Commission
Medicaid Disease Management Program OverviewMedicaid Disease Management Program Overview
Texas Association of Community Health Centers Annual MeetingTexas Association of Community Health Centers Annual MeetingOctober 26, 2004October 26, 2004
Maureen Mangotich MD, MPHMaureen Mangotich MD, MPHMedical Director, Provider and Community OutreachMedical Director, Provider and Community Outreach
McKesson Health SolutionsMcKesson Health Solutions
Agenda
Medicaid DM Program History
DM Program Overview
Opportunities for Collaboration with
Community Health Centers
Legislative Mandate
The Texas 78th Legislative Session (2003)
mandated State agencies to focus on the
healthcare needs of the underserved and
needy
The legislation mandates measurable
financial and clinical results, and
proactively reduced budgets
State RFP for Medicaid FFS DM Program
Program GoalsProgram Goals Improve health statusImprove health status
Increase adherence to national evidence based guidelines
Reduce overall medical costs Reduce overall medical costs Savings expectations – a minimum of 5%
of total expenditures for the eligible population served
Why Disease Management?
Clinic visitClinic visit NextNextClinic visitClinic visit
Treatment PlanTreatment Plan1-12 months
Late Rx Refill
Acute Sx – ER visit Avoidable
IP admit
State RFP for Medicaid FFS DM Program
Program Objectives Program Objectives Improve continuity of care Improve continuity of care Increase access to preventive care Increase access to preventive care Enhance clients’ relationship with their primary Enhance clients’ relationship with their primary
caregiver and other providerscaregiver and other providers Improve coordination and collaboration among Improve coordination and collaboration among
healthcare providers and other community healthcare providers and other community resourcesresources
Reduce unnecessary hospital admits, total Reduce unnecessary hospital admits, total hospital days, ER visitshospital days, ER visits
DM Vendor Selection
Multiple bidders summer ’03 for 1/04 awardMultiple bidders summer ’03 for 1/04 award Initial plan to award South and North separatelyInitial plan to award South and North separately
2 Finalists 7/1/04 McKesson chosen for entire state7/1/04 McKesson chosen for entire state
Major reasons:- Guaranteed savings
- Risk contract – 100% of fees
- 60 day implementation
McKesson Health Solutions Profile
Six care centers Six care centers 4 in Mainland USA, 1 in Puerto Rico, 1 in Westlake TX Employ ~ 400 nurses in N. America
Nurse Advice Line (Triage Services)Nurse Advice Line (Triage Services) ~ 25MM covered lives in Triage
Disease Management ProgramsDisease Management Programs Asthma, COPD, Diabetes, CAD, Heart Failure 80 DM clients (MCO, Medicaid, Employers, Pharma 8 Medicaid Contracts: Colorado, Florida, Mississippi, Montana,
New Hampshire New Jersey, Oregon, Puerto Rico, Washington Accredited by JCAHO, NCQA, URAC
Heart Failure ProgramHeart Failure ProgramHeart Failure ProgramHeart Failure Program
McKesson DM Program Results
Diabetes ProgramDiabetes Program Diabetes ProgramDiabetes Program
Asthma ProgramAsthma ProgramAsthma ProgramAsthma Program
•89% increase in ACE-inhibitor prescriptions
•24% increase in annual flu vaccinations
•114% increase in pts weighing themselves daily
•155% increase in pts keeping a weight record
•44% increase in pts following a low-salt diet
•33% increase in pts who do SMBG monitoring
•70% increase in aspirin use
•22% reporting lower blood glucose levels
•20% show improved functional status
•91% increase in patients with action plans
•85% in asthmatics who own peak flow meters
•34% increase in asthmatics using spacers
Economic Impact
Behavior changes lead to improvements in Behavior changes lead to improvements in compliance, functional status, symptom controlcompliance, functional status, symptom control, , andand reduced service utilizationreduced service utilization
Claims-based studies show:Claims-based studies show: Range:Range:
• Reduction in inpatient hospitalizationsReduction in inpatient hospitalizations• Reduction in ED visitsReduction in ED visits• Gross savings per person per annumGross savings per person per annum• Return on investmentReturn on investment (Dollars saved for every dollar spent)(Dollars saved for every dollar spent)
15% – 53%15% – 53%
5% – 31%5% – 31%
$279 – $2,560$279 – $2,560
$1.55 – >$3.00$1.55 – >$3.00
The Texas Medicaid Enhanced Care Program
Disease Management Disease Management
Care CoordinationCare Coordination
24/7 Triage Services24/7 Triage Services
Who is eligible to participate?
Eligible Fee-For-Service Medicaid clients with asthma, diabetes, heart failure, CAD and COPD
Opt Out Program Clients are automatically enrolled
unless they choose not to participate
Identification of Program Enrollees
State DataState Data
ClaimsClaimsEligibilityEligibility ProvidersProviders
Client- Client- Provider Provider
LinksLinksTarget Target ClientsClients
Medical Home
DM Services Support Pts Between Office Visits
24 x 7 24 x 7 nurse nurse triage triage
serviceservice
Proactive Proactive Outbound Outbound
Nurse CallsNurse Calls
Community Community Support Support
Services Services
Promotora Promotora outreach/ outreach/
enrollment enrollment contactscontacts
Face to face Face to face nurse nurse
contactscontacts
Provider Provider mailing with mailing with patient list patient list
Care Care coordination coordination
services services
Pt mailings: Pt mailings: educational educational materials, materials, reports, reports,
remindersreminders
Audiohealth Audiohealth
Library Library (English (English
and and Spanish)Spanish)
Coordinate
Triage &Navigate
R.N.M.D.Patient
MD Reports: MD Reports: Clinical Clinical alerts, pt alerts, pt updates updates
Primary Care 60% of visits are for information and reassurance rather than treatment (7) Our triage service directs 40% to home/self care
ER Care 53% of visits are not urgent; (3)
Our triage service directs more than 86% away from ER and Urgent Care facilities
Select High Cost Surgical Procedures/Bed DaysSignificant variation of surgical treatments for common diseases (8)
Chronic IllnessChronic illnesses drive 60% of the nations medical care costs (1) 1 out of 3 callers have a chronic /catastrophic or mental health condition – 75% elect to enroll (2)
Sources (1) The Robert Wood Johnson Foundation, Annual Report, 2000 (2) Internal McK Research, 2001 and 360 pilot results, March, 2002
(3) National emergency care utilization report -NCHS, 2001 (4) Harris Interactive and Harvard School of Public Health Research Study, 2000(5) Cyber Dialogue and Deloitte & Touche, Strategy and E-Health, 2001 (6) Health Affairs Article, 2001 and Agency for Healthcare Research and Quality
(7) Modern HealthCare, June, 2000; source: Agency for Healthcare Research and Quality(8) The Dartmouth Atlas, 2000
Evidence supporting nurse triage
Avoidable Admissions1 out of every 9 admissions is avoidable with improved access to care (6)
Member ParticipationIn Medical Decisions90% of consumers want greater participation in decision making. (4) 50 mm online health users (5)
A recent ground breaking RCT just competed by the Geffen School of Medicine at UCLA compared McKesson nurse triage of symptoms to a panel of Board Certified Pediatric
Emergency Medicine Specialists from a major Academic Institution … the result no significant differences in care recommendations
Randomized control studyN = 3,193 medical advice pediatric callsStudy period was 11 monthsReferred to 3 categories ED/Urgent Care, Office Care, Self CareCallers were randomly routed to either a physician or nurse. The caller was then triaged and the result were recorded. There was no significant difference in where the physician recommended the caller seek care vs where the nurse recommended the caller seek care
0
10
20
30
40
50
60
70
80
ED/Urgent Care Office Care Self Care
Physician
Nurse
11.4% 10.7%
19.0% 18.7%
69.6% 70.6%
Proof that our triage clinical content and nurse quality management processes are working….
Tiered Interventions based on risk
Proprietary Risk StratificationProprietary Risk Stratification
STABLE STABLE (Level 1)(Level 1)
Audio health Library
Educational Mailings
24x7 nurse line
Provider AlertsProvider Alerts
AT RISK(Level 2)
Proactive callsProactive calls Level 2 services
Case mgmt referralsCase mgmt referrals
HIGH RISK(Level 3)
In-person visitsIn-person visits
Home Monitoring Home Monitoring DevicesDevices
Level 1 services Level 1 services
DM Program Launch – November 2004
Physician Communications
Patient Patient CommunicationsCommunications
DM Program IntroDM Program IntroPt List, Guideline Pt List, Guideline info. Program info. Program brochurebrochure
DM Welcome letterDM Welcome letterToll free numberToll free numberBusiness reply cardBusiness reply cardCalling card Calling card incentiveincentive
Enrollment ContactsEnrollment Contacts
Physician CommunicationsIntroductory Mailing
Cover letter with list Cover letter with list of physician’s of physician’s patients eligible for patients eligible for enrollment enrollment
Program InformationProgram Information Clinical guidelines Clinical guidelines Stepped Inserts:Stepped Inserts:
Program benefits to pts, provider
FAQs
Introductory Materials Provided to All clients Eligible to Participate
Personalized letterPersonalized letter 44thth grade reading level grade reading level Magnet with Toll Free Magnet with Toll Free
numbernumber Easy to read educational Easy to read educational
pamphletpamphlet Mail or hand deliveredMail or hand delivered
Personalized Patient Education
Assess: Maslow's hierarchy of needs, Prochaska/ readiness to change, clinical, functional, utilization, knowledge level, risk metrics and QOL
Teach: Condition knowledge, self-management skills, medication compliance, prevention, proactive management
Reinforce improvement: Action plans, monitoring, 24/7 nurse advice line, health counseling and fulfillment
Modify Goals: Re-assessment 6 and 12 months, re-
education, monitoring, etc.
Personalized Support: Action Plans Developed for All Program Enrollees
Prevention
Education
Screening and testing
Medication reminders
Warning signs and symptoms
Provider partnering
Personalized Support: Special Needs Coordination and Physician Alerts
Compliance and adherence
Three Severity Levels
Level 3 alerts faxed to office/clinic after nurse call
Access concerns
Utilization issues
Financial issues
How do Providers Benefit?
Improvement in patient self-mgmt skills:Improvement in patient self-mgmt skills: Better adherence to medical regimen Earlier recognition of decompensation and
PCP contact for urgent evaluation Improved continuity of care Improved continuity of care
Reduced “no-shows” for office appts Fewer after-hours calls Fewer calls to nurse staff during office hours
Program Launch (first 90 days)Program Launch (first 90 days) Orient CHC staffOrient CHC staff to new programto new programReview lists of identified DM enrollees Review lists of identified DM enrollees
Validate identified cases and provider linkages Recommend appropriate level of DM
services/support Identify CHC clients not currently on DM program
rolls who might be eligibleRecommend CHC Representative to serve on Recommend CHC Representative to serve on
Statewide Provider Advisory BoardStatewide Provider Advisory Board
Opportunities for Collaboration with Texas Community Health Centers
Opportunities for Collaboration with Texas Community Health Centers
Post Launch PeriodPost Launch Period Coordinate resources to optimize Coordinate resources to optimize
appropriate access to primary care appropriate access to primary care servicesservices Promote 24x7 telephone triage service to
reduce office/ER visits for c/o appropriate for self-care
Expedited appt access for DM managed clients with urgent clinical issues
Opportunities for Collaboration with Texas Community Health Centers
Longer Term GoalsLonger Term GoalsDemonstrate value of collaborative careDemonstrate value of collaborative care
Number of similarities between DM program and CHCs in mission, approach, services offered
Share tool kitsShare tool kitsEducate clinicians in population Educate clinicians in population
management tools, techniquesmanagement tools, techniques
Program Contact Information
In-State Program Manager
Barbara Ramsey – (866) 645-0312
HHSC Senior Policy Analyst
Geri Willems– (512) 491-1460